Evidence Based Practice (EBP)

DR. AIDAH ABU ELSOUD ALKAISSI

DIRECTOR OF NURSING & MIDWIFERY DEPARTMENT
MEDICAL & HEALTH SCIENCES COLLEGE
CO-ORDINATOR OF MASTER OF COMMUNITY MENTAL HEALTH NURSING PROGRAM
GRADUATE STUDIES FACULTY
AN-NAJAH NATIONAL UNIVERSITY
[email protected]
0597395520
What is Evidence Based
Practice (EBP)

 Evidence-based practice refers to applying

the best available research evidence in the
provision of health, behavior, and education
services to enhance outcomes.
 Evidence-based practice has been defined
similarly by different groups:

 The American Psychological Association

defines EBP as “the integration of the best
available research with clinical expertise in the
context of patient characteristics, culture, and
preferences.”
Evidence quality can be assessed based on the source type
Rating System for the Hierarchy of Evidence appropriate for
treatment or intervention

Level 1: Systematic review or meta-analysis of all relevant

randomized controlled trials (RCTs), or evidence-based
clinical practice guidelines based on systematic reviews of
RCTs

Level 2: Evidence from at least one well-designed RCT

Level 3: Evidence from a well-designed controlled trial

without randomization

Level 4: Evidence from well-designed case-control and

cohort studies

Level 5: Evidence from systematic reviews of descriptive

and qualitative studies

Level 6: Evidence from a single descriptive or qualitative

study

Level 7: Evidence from the opinion of authorities and / or

reports of expert committees
National Health Service
According to the study designs and critical appraisal of
prevention, diagnosis, prognosis, therapy, and harm studies
("Levels of Evidence". CEBM)

Level A: Consistent Randomised Controlled

Clinical Trial, cohort study, clinical decision
rule validated in different populations.

Level B: Consistent Retrospective Cohort,

Exploratory Cohort, Outcomes Research,
case-control study;

Level C: Case-series study (descriptive)

Level D: Expert opinion without explicit

critical appraisal‫قييم نــقدي صرـيـح‬
‫بــــن تــــ‬
‫رـأي دوـ‬
A case-control study

 A case-control study is designed to help determine if

an exposure is associated with an outcome (i.e.,
disease or condition of interest). In theory, the case-
control study can be described simply. First, identify
the cases (a group known to have the outcome) and
the controls (a group known to be free of the
outcome).
 is a type of observational study in which two existing
groups differing in outcome are identified and
compared on the basis of some supposed causal
attribute.
Case series study

 Case series study is descriptive only (no

comparison group). It includes group of
patients with certain disease or with
abnormal sign and symptom.

 while cohort study include healthy people

but they exposed to certain exposure and
follow them for certain period to see if the
outcome develop or not (incidence study).
 Cohort studies

 Cohort studies are a type of

medical research used to investigate the causes
of disease and to establish links between risk
factors and health outcomes. The
word cohort means a group of people. ...
Prospective” studies are planned in advance
and carried out over a future period of time
case report

 Case report and clinical study. is a

detailed report of the symptoms, signs,
diagnosis, treatment, and follow-up of an
individual patient. 

 Case reports may contain a demographic

profile of the patient, but usually describe an
unusual or novel occurrence.
Levels of evidence
 A systematic review
 A systematic review aims to provide an exhaustive summary of
literature relevant to a research question. The first step of a
systematic review is a thorough search of the literature for
relevant papers. The Methodology section of the review will list
the databases and citation indexes searched, such as 
Web of Science, Embase, and PubMed, as well as any individual
journals.

 Next, the titles and the abstracts of the identified articles are
checked against pre-determined criteria for eligibility and
relevance. This list will always depend on the research problem.
Each included study may be assigned an objective assessment of
methodological quality preferably using a method conforming to
PRISMA (the current guideline)or the high quality standards of
Cochrane collaboration.
 Meta analysis
 Meta-analysis is a statistical technique for amalgamating ‫دمج‬,
summarising, and reviewing previous quantitative research. 

 By using meta-analysis, a wide variety of questions can be investigated,

as long as a reasonable body of primary research studies exist.  

 Selected parts of the reported results of primary studies are entered into
a database, and this "meta-data" is "meta-analyzed", in similar ways to
working with other data - descriptively and then inferentially to test
certain hypotheses.

 Meta analysis can be used as a guide to answer the question 'does what
we are doing make a difference to X?', even if 'X' has been measured using
different instruments across a range of different people.  Meta-analysis
provides a systematic overview of quantitative research which has
examined a particular question.
Meta analysis

 The appeal‫ استئناف‬of meta analysis is that it in effect

combines all the research on one topic into one large
study with many participants.

 Meta-analysis has been used to give helpful insight into:

 the overall effectiveness of interventions (e.g.,
psychotherapy, outdoor education),
 the relative impact of independent variables (e.g., the
effect of different types of therapy), and
 the strength of relationship between variables.
 Randomized Controlled Study
 A randomized controlled trial (RCT) is a specific type of scientific
experiment, and the gold standard for a clinical trial.

 RCT are often used to test the efficacy of various types of 

intervention within a patient population.

 RCT may also provide an opportunity to gather useful information

about adverse effects, such as drug reactions.

 The key distinguishing feature of the usual RCT is that study

subjects, after assessment of eligibility and recruitment, but before
the intervention to be studied begins, are randomly allocated to
receive one or other of the alternative treatments under study
Efficacy & Effectiveness

 Efficacy can be defined as the performance of

an intervention under ideal and controlled
circumstances,

 whereas effectiveness refers to its
performance under 'real-world' conditions
 Randomized Controlled Study

 Random allocation in real trials is complex, but conceptually, the

process is like tossing a coin.

 After randomization, the two (or more) groups of subjects are

followed in exactly the same way, and the only differences
between the care they receive, for example, in terms of
procedures, tests, outpatient visits, follow-up calls etc. should be
those intrinsic to the treatments being compared.

 The most important advantage of proper randomization is that it

minimizes allocation bias, balancing both known and unknown
prognostic factors, in the assignment of treatments."
Random allocation

 Random allocation
 Randomized controlled trials (RCT) are known as the best
method to prove causality in spite of various limitations.
Random allocation is a technique that chooses individuals for
treatment groups and control groups entirely by chance with no
regard to the will of researchers or patients' condition and
preference. This allows researchers to control all known and
unknown factors that may affect results in treatment groups and
control groups.

 The participants are randomly allocated according to the

randomization list generated by the GraphPad® software,
developed by GraphPad Software Inc, San Diego, California, USA
Random allocation

 https://www.graphpad.com/quickcalcs/rando
mize1/
Assign subjects to groups
 A cohort study
 A cohort study tracks two or more groups forward from exposure to
outcome.

 This type of study can be done by going ahead in time from the present
(prospective cohort study) or, alternatively, by going back in time to
comprise the cohorts and following them up to the present (retrospective
cohort study).

 A cohort study is the best way to identify incidence and natural history of
a disease, and can be used to examine multiple outcomes after a single
exposure.

 However, this type of study is less useful for examination of rare events or
those that take a long time to develop.
A cohort study
 A cohort study should provide specific definitions of exposures and
outcomes: determination of both should be as objective as possible.

 The control group (unexposed) should be similar in all important

respects to the exposed, with the exception of not having the
exposure.

 Observational studies, however, rarely achieve such a degree of

similarity, so investigators need to measure and control for
confounding factors.

 Reduction of loss to follow-up over time is a challenge, since

differential losses to follow-up introduce bias.
A case control study
 A case-control study is a type of study design used widely, often in 
epidemiology.

 It is a type of observational study in which two existing groups differing

in outcome are identified and compared on the basis of some supposed
causal attribute.

 Case-control studies are often used to identify factors that may

contribute to a medical condition by comparing subjects who have that
condition/disease (the 'cases') with patients who do not have the
condition/disease but are otherwise similar (the 'controls').

  They require less resources but provide less evidence for causal
inference than a randomized controlled trial.
A case control study

 For example, in a study trying to show that people who

smoke (the attribute) are more likely to be diagnosed with
lung cancer (theoutcome), the cases would be persons with
lung cancer, the controls would be persons without lung
cancer (not necessarily healthy), and some of each group
would be smokers. If a larger proportion of the cases smoke
than the controls, that suggests, but does not conclusively
show, that the hypothesis is valid.

 The case-control study is frequently contrasted with 

cohort studies, wherein exposed and unexposed subjects
are observed until they develop an outcome of interest
 A case series
 A case series (also known as a clinical series) is a medical research 
descriptive study that tracks patients with a known exposure given similar
treatment or examines their medical records for exposure and outcome.

 It can be retrospective or prospective and usually involves a smaller

number of patients than more powerful case-control studies or 
randomized controlled trials. Case series may beconsecutive[2] or non-
consecutive,[3] depending on whether all cases presenting to the reporting
authors over a period were included, or only a selection.

 Case series may be confounded by selection bias, which limits statements

on the causality of correlations observed; for example, physicians who
look at patients with a certain illness and a suspected linked exposure will
have a selection bias in that they have drawn their patients from a narrow
selection (namely their hospital or clinic).
A case report

  a case report is a detailed report of the 

symptoms, signs, diagnosis, treatment, and
follow-up of an individual patient. Case
reports may contain a demographic profile of
the patient, but usually describe an unusual or
novel occurrence.
A case report

 Most case reports are on one of six topics:

 An unexpected association between diseases or 
symptoms.
 An unexpected event in the course of observing or
treating a patient.
 Findings that shed new light on the possible pathogenesis
 of a disease or an adverse effect.
 Unique or rare features of a disease.
 Unique therapeutic approaches.
 A positional or quantitative variation of the anatomical
structures.
Editorial

  is an opinion piece written by the senior editorial

staff or publisher of a newspaper ormagazine.

 Editorials may be supposed to reflect the opinion

of the periodical.

 Editor:a person having managerial and sometimes 
policymakingresponsibility for the editorial
 part of a publishing firm or of anewspaper, magazi
ne, or other publication.
Editorials

 Editorials are typically published on a special

page dedicated to them, called the editorial
page, which often also features 
letters to the editor from members of the
public