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The EBP Optometry Project.

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When clinical decisions are made in an evidence-based manner, we can think of this process as taking place in five stages, or steps, as follows: Ash, Acquire, appraise, apply and audit

Evidence-based practice involves clinical decision making using systematic evidence as well as clinical expertise and patient’s preferences, within the context of the workplace (Satterfield, 2009). Optometrists, like other health professions, have a desire and clinical responsibility to help their patients see effectively and be as healthy as possible please Code of Conduct for optometrists from the Optometry Board of Australia.

EBP offers a framework for deciding which course of clinical action may be most appropriate for any given patient. It is difficult to have the answer to every clinical question, particularly as patients vary. Instead, having the EBP knowledge and skills allows you answer your own individual questions - for your particular patient. EBP should improve your practice and result in better outcomes for your patient. EBP is well-adopted by other health professions, for example medicine, speech pathology, psychology and nursing. It is the project team’s goal that graduates and practitioners will be able to answer a clinical question using EBP from after completing the materials on this site.

What is Evidence-based Practice?

There are many definitions of evidence-based practice. One of the most widely cited is by Sackett (1996) and refers specifically to evidence-based medicine, but applies similarly to health care in general:

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making 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.”

The concept has been widely embraced in a wide range of allied health areas, and the term “evidence-based practice” is used, as in this definition by Dawes et al (2005):

"Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources.”

More recently, Satterfield et al (2009) pointed out that EBP is limited or facilitated by the environment in which the clinical decision is made (the clinical organizational structure), so that EBP is a combination of:
 

  1. The best external research evidence
  2. The practitioner’s expertise and experience
  3. The patient’s characteristics, presentation and preferences
     

all set within the organisational and environmental context of the practice environment.

  • Essentially, evidence-based practice can be thought of as a process in which clinical decisions are made in light of the best research evidence, existing practitioner expertise and knowledge and the patient’s preferences within the context of the clinic environment.

    The following diagram helps to visualise the relationship of each of these with the final product of clinical decision-making as the culmination of using all of the elements together.

    Putting this all together is a skill that needs to be learned, but it is essentially what experienced clinicians of all professions do all the time - EBP just makes this clear and easier to teach practice at an undergraduate level. It also clarifies our approach.

    In conclusion, when practitioners consider all of the factors shown in the above diagram as part of clinical decision-making, the process they have followed is evidence-based practice. This EBP process can be defined into 5 steps of EBP.

    From Satterfield et al (2009) Toward a Transdisciplinary Model of Evidence-based Practice. Millbank Quarterly 87(2): 368-390. (With permission).
     

  • All through the EBP process we take into account the characteristics of the patient in front of us. For example, we search for evidence relevant to this type of patient and population. At the 'Apply' stage, a clinical decision is made on the basis of that evidence, we take the patient's preferences and values into account. We discuss the evidence with the patient and so that the clinical decision takes into account not only the evidence and our expertise but also the patient's perspective. 

     

  • As indicated above, clinical decisions are made in the context of the practice environment, which may limit or facilitate the EBP process. For example, the practice may not provide Internet access, in which case the practitioner may not have immediate access to research evidence. 

    However, the practitioner would need to not only access but also appraise the evidence before applying it as part of clinical decision making. This in itself is a limitation to EBP in optometry, since proper appraisal of research reports is time consuming, and not feasible in a chair-side situation. In medicine and some allied health areas, systems are in place to provide pre-appraised reports of the available research evidence, but unfortunately no such systems exist currently for optometry or any eye care profession.

    Another practice environment factor is the ethos of the practice, which may support the use of best available research evidence, or not. Thus, practitioners may be part of a mind-set in which EBP is the norm, and is encouraged, or in which the EBP process is unusual and not generally embraced. This and other environmental factors could influence the extent to which each practitioner is likely to follow EBP process when making clinical decisions.

     

  • This term refers to the highest quality evidence from research that is available to the practitioner, and “highest quality” refers to grading of published research based on the extent to which the evidence provided by this research can be considered reliable. One such grading system comes from the Australia based National Health and Medical Research Council (NHMRC). Note though that low level 'evidence' may be found in non-research sources. For example, the Centre for Evidence-based Medicine (CEBM) lists expert opinion as the lowest of five levels of evidence, and points out that if the best available evidence is very low level/low quality, our advice to patients should include information on the degree of reliability or otherwise of the evidence.

    According to the NHMRC scale, the CEBM table and other evidence heirarchies of this kind, case reports are toward the low end of the scale. They are of limited reliability because they are observations of individual cases. If the case involves an intervention, the reported results may reflect a placebo effect since there was no comparison with a placebo intervention. In case studies not involving intervention, the patient’s response may reflect a Hawthorne effect if the patient knew they were being observed. At the other end of the scale we have randomized controlled studies and systematic reviews of such studies.

    These provide more reliable evidence because a larger sample of the population was included (individual cases may not be typical of the wider population), the sample was randomly allocated to groups treated differently (e.g. with real, placebo or no interventions) and the study was controlled (with a placebo comparison). In addition, a high quality study would be expected to include masking of the patients and the researchers, so that neither were aware in which cases the placebo or the real intervention applied. This minimizes the chance of either being biased toward a certain type of outcome, and illustrates the fact that we cannot assume that a randomized controlled study provides solid evidence. The details of the study methodology must be understood in order to assess internal validity, that is, to determine whether the results may reflect factors such as bias or other flawed methodology.

    For any clinical question, if research evidence at the high end of the scale (e.g. a systematic review of randomized controlled trials) is in publication, but the practitioner does not access and use it as part of clinical decision making, the process followed cannot be said to be ‘evidence-based’. However, if high end research evidence is not in publication, the practitioner has no option but to use lower quality evidence, such as studies that were not properly randomized, or perhaps even no research evidence. In such circumstances, the process does fit the definition of evidence-based practice, if the practitioner is using the best available evidence (the word “available” is often used in definitions of EBP ; Sackett, 1996; Cochrane, 2012) together with clinical experience/expertise and the patient’s preferences in the context of the practice environment.

    So, “best available research evidence” is the highest quality (most reliable) research that is in publication, and therefore available to the practitioner for appraisal and application as the basis of clinical decision making. Note that details of the research may not be easily available, because they are often not provided via ‘open access’ (freely available to all via the Internet) so they can be accessed only with journal subscription or as part of professional body membership or University enrolment. The evidence is thought of as being available to the practitioner if full details are published somewhere, even if access incurs cost.

    The evidence that the practitioner finds must be appraised before being applied - See Step 3: appraise of the EBP process.

     

  • Another term in the definitions of EBP is “clinical expertise” or “clinical experience”. To refer again to Sackett (1996) “By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care.” So, this aspect of EBP is the experience and knowledge the practitioner has gathered through hands-on clinical practice.

     

  • In the profession of optometry, responsibilities for eye and general health care make evidence-based practice (EBP) essential. Current optometry curricula include isolated teaching and learning strategies that aim to develop the knowledge and skills required for EBP, but our recent pilot work (1) suggests that optometry graduates have not uniformly adopted EBP. Programs in other disciplines such as medicine and speech pathology have recognized and addressed this issue by embedding teaching and learning strategies in their curricula. For example, the Faculty of Medicine at the University of New South Wales has developed and implemented an online resource to support learning and teaching in EBP. Our review of the literature confirms this type of resource as a valid and effective means of developing EBP knowledge and skills. This Project aims to increase the use of evidence-based practice in Optometry. The Project team is comprised of representatives from Optometry Schools in Australia and New Zealand as well as EBP experts. The project is funded by a grant awarded by the Office for Learning and Teaching (formerly the Australian Learning & Teaching Council). It runs from December 2011 through to December 2013. Please enjoy browsing this website and do get in touch with us if you are interested in finding out more about the Project- we would love to hear from you.

     

  • The need for critical thinking and an evidence-based approach in optometric practice is widely acknowledged. Several moves and publications illustrate this point.

    In 1997, the Cochrane Collaboration developed an arm known as the Cochrane Eyes and Vision Group (http://eyes.cochrane.org/), aiming “to prepare, maintain and promote access to systematic reviews of all the interventions used to prevent or treat eye diseases and/or visual impairment [and to] consider the evidence for interventions that aim to help people adjust to visual impairment or blindness”. McBrien (1998) noted that the expanding clinical scope of optometry, with areas of expertise including behavioural optometry and ocular therapeutics, increases the importance of an evidence-based approach to optometric practice. In 1999, the journal Evidence-Based Ophthalmology was introduced, with a focus on “an evidence-based (as opposed to an anecdotal) approach to eye care. Rather than undertaking a given treatment because ‘that's how we treat this condition’” (however, the journal closed in 2011 because the “publisher wishes to provide continued support for evidence-based research in formats that reach larger audiences”). The first book focused specifically on evidence-based eye care was published in 2006 (Kertes and Johnson, 2006).

    In 2003, the US-based Institute of Medicine (IOM) made recommendations for education programs in health care, including optometry. The IOM developed five core competencies for clinicians in all health care areas, and one of these directly called for an evidence-based approach to practice: “Use evidence-based practice: To integrate the best research with clinical expertise and patient values”. Based on these recommendations, Elam (2004) pointed to a need for competences not only for entry-level optometrists, but also for the mature practitioner, including competency in evidence-based practice. In Australia, the federal government’s National Eye Health Framework (Australian Government Department of Health and Ageing, 2005) states that “Improving the evidence base” for eye care is a key area for action. Another key area identified in the framework is “Improving the systems and quality of care” with specific action items on continuing professional development and training and the promotion of evidence-based guidelines for eye care. From September 2008, an MSc program in Evidence Based Practice in Ophthalmology has been offered by the University of Teeside, U.K. At the University of New South Wales, the Master of Optometry program includes a compulsory course in Evidence-based Optometry.

    In a review focused in part on evidence in optometric practice, Adams (2007) reminds us that vision research is fundamental to optometry, underpinning every aspect of our practice. He also highlighted the importance of undergraduate and postgraduate education in optometry, to ensure that practitioners understand the principles of evidence-based eye care and have the skills needed to use this approach in their practice. As noted by Anderton (2007), it is essential for optometrists to be able to assess whether claims of statistical significance are justified, and to determine whether the findings have clinical significance. More recently, Elliott (2012) discusses the importance of evidence-based clinical decision-making, and points out that optometrists should not only be accessing and using best evidence, but could also contribute to the pool of evidence, based on clinical experience and patient data.

    Everything on the list below (and more) is well worth a read:

    • Adams, A.J. (2007) The role of research, evidence and education in optometry: a perspective. Clin Exp Optom 90(4): 232-237.

    • Anderton, P.J. (2007) Implementation of evidence-based practice in optometry. Clin Exp Optom 90(4): 238-243.

    • Elam, J.H. (2004) Competency-based optometric education. Optometry 75(2): 75-78.

    • Elliott D.B. (2012) Evidence-based optometry and in-practice research. Ophthalmic Physiol Opt 32(2): 81-81.

    • Kertes, P.J. and Johnson, T.M. (2006) Evidence-based eye care. Lippincott, Williams and Wilkins. McBrien, N. (1998) Optometry: an evidence-based clinical discipline. Clin Exp Optom (Editorial) 81(6): 234-235.

  • The roots of evidence-based practice are in evidence-based medicine. The history of evidence-based medicine has been well documented and includes primitive experiments to test the effectiveness of practices such as bloodletting (Claridge and Fabian, 2005). 

    In 1972, Archie Cochrane pointed out the importance of properly testing the effectiveness of health care strategies, and stressed the role of randomised controlled studies to provide evidence on which health care is based. The term "evidence-based medicine" was introduced by Guyatt et al in 1992 to shift the emphasis in clinical decision making from "intuition, unsystematic clinical experience, and pathophysiologic rationale" to scientific, clinically relevant research.
    An early photograph of bloodletting, from Wikimedia Commons, courtesy of the Burns Archive.

    The formalized concept was embraced by many, but also elicited some criticisms, including that evidence-based medicine relies too heavily on research. It was still being described by some as a “new approach” almost twenty years later (Selvaraj et al, 2010), suggesting that it has taken some time to become integrated into the medical profession worldwide.  

    In 1996, Sackett et al explained evidence-based clinical decision making as a combination of not only research evidence but also clinical expertise, taking into account the patient’s preferences. Clinical expertise was defined as the “proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice”.

    Since then, evidence-based decision making has been widely accepted by allied health areas (nursing, dentistry, speech pathology, psychology, social work, public health and many others). In 2003, a statement on evidence-based practice was prepared by the delegates of the Evidence-based Health Care Teachers and Developers conference. The conference was held in Sicily, and the statement is known as the Sicily Statement (Dawes et al, 2005). It helped to introduce the broader concept of evidence-based decision making to health care generally.

    Health care practitioners work in a range of clinical environments that are likely to influence decision making using EBP. In 2009, Satterfield et al developed a transdisciplinary model for evidence-based practice. This model depicts the three core components of EBP (best available research evidence, clinical expertise and patient’s preferences) within the broader clinical or organizational context. In a sense, the organizational context is a fourth EBP component.