Training Specific Treatment Techniques: The Next Step in Implementation of EBP?
de Riesthal, Michael, Journal of Medical Speech - Language Pathology
The field of medical speech-language pathology is moving toward an evidence-based practice (EBP) approach to clinical decision making. This movement spawned the development of practice guidelines and systematic reviews designed to improve clinician access to the literature and reduce the time spent repeatedly searching, appraising, and modifying management routines (Sackett, Richardson, Rosenberg, & Haynes, 2000). In the area of neurogenic communication disorders, for example aphasia and dysarthria, various groups are developing clinical practice guidelines and systematic reviews of the treatment literature, as well as systems for rating these products.
Sackett et al. (2000) instruct that such guidelines should have two primary components--the evidence summary and the detailed instructions for applying that evidence to a patient. The evidence summary should identify all relevant evidence regarding a particular treatment and grade the evidence for its validity. Moreover, it should be updated continually with the latest research findings. The instructions for implementing the treatment must be of sufficient detail to permit replication of the treatment in one's own clinic.
The second component--the translation of research treatment procedures into clinical practice--may be the most difficult aspect of the implementation of EBP. This forum will describe the status of the two primary components for guidelines within the field of medical speech-language pathology and propose an additional step in translating research into clinical practice.
ASSESSING THE VALIDITY OF TREATMENT EVIDENCE
One challenge to selecting a guideline is for clinicians to decide if it is valid (Sackett et al., 2000). Sackett et al. (2000) suggest that a guideline should include a comprehensive, reproducible literature review within the past 12 months. Moreover, each recommendation should be evaluated for level of evidence and supported with a specific citation. The American Speech-Language-Hearing Association's (ASHA) National Center for Evidence-Based Practice in Communication Disorders (N-CEP) has developed a registry to evaluate both EBP guidelines and systematic reviews, which can be found at http://www.asha.org. To evaluate practice guidelines, N-CEP utilizes a method called the Appraisal of Guidelines for Research and Evaluation (AGREE; http://www.agreecollaboration.org), which assesses 23 key items across six domains, including scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence. Based on the total score across domains, each guideline is provided with an overall assessment and categorized as highly recommended, recommended with provisos, or not recommended. To evaluate systematic reviews, N-CEP examines five indicators of review quality: clarity of the clinical question, criteria for study inclusion, details of search strategy, assessment of study quality, and reproducibility of the assessment. The ASHA N-CEP registry permits clinicians to search for and select the best available practice guideline or systematic review, which may lead to the selection of the most appropriate treatment for a particular patient.
DEVELOPING CLINICAL PRACTICE GUIDELINES
Sackett et al. (2000) recommend that the development of practice guidelines and systematic reviews should be left to those with the experience and resources (time and money) to perform the task, for example, larger national or international groups. They caution that having groups of local clinicians develop their own guidelines would unnecessarily reduce the time practitioners have to manage individual patients. So, who is generating guidelines in medical speech-language pathology? Various international organizations, including the New Zealand Guidelines Group, the Royal College of Physicians, the Royal College of Speech and Language Therapists, and the Cochrane Collaboration, have generated clinical practice guidelines and systematic reviews in target areas of medical speech-language pathology. …