Transcript Evidence-Based Practice - Collaborative Family Healthcare

Barbara Walker, Ph.D.
Clinical Professor, Department of Psychology
Professor, Department of Family Medicine
University of Colorado, Denver
Jeffrey L. Goodie, Ph.D., ABPP/ LCDR, USPHS
Assistant Professor of Family Medicine
Uniformed Services University of the Health Sciences
Bethesda, MD
Helen L. Coons, Ph.D., ABPP
President and Clinical Director, Women’s Mental Health Associates
Philadelphia, PA
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Drs. Walker, Coons and Goodie have not had any
relevant financial relationships
during the past 12 months.
What is the scientific basis for this talk?
In this symposium, we will define evidence-based
practice (EBP), introduce participants to the
associated skill-set, tools and new resources for
doing EBP, and illustrate how it can be translated it
into both primary and specialty collaborative care
settings.
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Describe how evidence-based practice is used for
clinical decision-making and the 5 steps associated
with this process.
Describe why it is necessary to adapt evidence-based
methods for use in primary care.
List examples of evidenced based assessment and
intervention strategies to improve physical and
psychosocial outcomes among women seen in
collaborative ob/gyn and oncology practices.
Describe how several interventions have been adapted
to be effective in a primary care environment.
What do you plan for this talk to change in the
participant’s practice?
 Be familiar with and be better able to use evidence-
based practice skills for clinical decision-making in
collaborative care settings.
 Increased ability to apply gender-specific research to
improve outcomes in collaborative ob/gyn and oncology
settings.
 Increased use of evidence-based practice strategies that
have been adapted for use in primary care, specifically
with regard to insomnia, weight management, and
PTSD.
A learning assessment is required for CE credit.
1) List the 5 specific steps associated with clinical
decision-making in evidence-based practice.
2) Name and explain how to access and search at least 2
databases that contain synthesized evidence-based
research.
3) Give at least one example of how evidence based care
can improve health and psychosocial outcomes.
4) Describe how evidence-based treatment has been
adapted and found to be effective in primary care for
treating insomnia, weight, and/or PTSD.
Session #
October __, 2011
0:00 AM
1) Fundamentals of Evidence-Based Practice: It’s more than applying
evidence-based treatments (Barbara Walker)
2) Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and
PTSD (Jeffrey Goodie)
3) Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and
Oncology Practices: Strategies to Improve Physical and Psychosocial
Outcomes (Helen Coons)
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
EVIDENCE BASED MEDICINE
Sackett et. al
1997
What should I do for this particular
patient in front of me?
Straus et. al,
2011 (4th ed.)
Best available
research
evidence
CD
Patient’s values
Clinical
Expertise
Best
research
available
Clinical
Expertise
CD
Patient
characteristics,
culture and
preferences
“The integration of the best available
research with clinical expertise in the context
of patient characteristics, culture, and
preferences” (became policy of the American
Psychological Association in August, 2005)
OPERATIONALIZATION :
5 STEPS
Best
research
available
Patient
characteristics,
culture,
preferences
1. ASK
2. ACQUIRE
CD
Clinical
Expertise
3. APPRAISE
4. APPLY
5. ASSESS
CD
Evidence-based Practice
TOP DOWN:
What is the most effective
intervention for this particular
disorder?
(ESTs, EB guidelines)
BOTTOM UP:
What should I do for this
particular patient in front
of me?
(Clinical Decision Making)
EBIDM: Eddy, D. Health Affairs, 24, no.1
(2005):9-17
By Content


Therapy
Diagnosis
Harm
Etiology
Prognosis
Cost-effectiveness
By Format

Background

Foreground
THIS SLIDE COURTESY OF SUE
LONDON RUTH LILLY
LIBRARY
THIS SERIES COURTESY OF SUE LONDON
IUPUI LIBRARY
High Sensitivity
High Specificity
WHAT: Scientifically synthesized literature
WHERE: Specialized databases
HOW: Specialized search strategies/filters
Evidence that has already been
(scientifically) synthesized for us:
Syntheses
 Summaries
 Systems

Systems
HOW?
Start at the top
Summaries
(Clinical
Evidence,Uptodate,
Dynamed, ESTs, EB
guidelines)
Syntheses
Systematic Reviews
(COCHRANE)
Individual Studies
(Medline, Embase, PsycINFO,
Cinahl
•
•
•
•
•
EBP has two sides: Top-down and Bottom up (a
set of clinical decision-making resources and
tools)
Common language
Setting / Context matters
Need for primary and secondary literature studies
in collaborative care
Ultimate goal is to improve outcomes
www.ebbp.org has training modules
Adapting and Delivering Evidence-Based
Interventions: Weight, Insomnia, and PTSD
Jeffrey L. Goodie, Ph.D., ABPP
LCDR, USPHS
Assistant Professor, Dept of Family Medicine
Uniformed Services University
Outline

Three examples
 Weight
 Insomnia
 PTSD
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

Medical or Behavioral health providers
Outcomes
Challenges
Weight
Goodie, J. L., Hunter, C., Hunter, C., McKnight, T., LeRoy, K., & Peterson, A. (2005,
March). Comparison of weight loss interventions in a primary care setting: A pilot
investigation. Paper presented at the 26th Annual Meeting of the Society of Behavioral
Medicine, Boston, MA.
Specialty Care Evidence

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Identification
Setting realistic goals
Self-monitoring
Stimulus control
Exercise to maintain weight loss
"Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity
in adults.“ (1998). National Heart, Lung, and Blood Institute, NIH.
Does primary care provider delivered
evidence-based behavioral interventions for
weight result in more weight loss?
Procedures
Enhanced Care Group

Appointment 1
Set 10% weight loss goal for first 6 months
 Maintenance goal for second 6 months
 Discuss motivators and barriers
 Provided w/ calorie book
 Food diary for 12 days


Appointment 2 (2 – 4 weeks later)
Review food diary and C.A.M.E.S.
 Review barriers and motivators

Procedures
Enhanced Care Group, Cont’d

Appointment 3 (2 – 4 weeks later)
 Discuss
physical activity
 Provided w/ pedometer
 Set

baseline and increase by 10%
Appointment 4 – 5
 Review
progress. Again, discuss barriers and
motivators

Appointment 6
 Set

maintenance goals
1 year follow-up
Procedures
Minimal Contact Group

Appointment 1
 Discuss
cutting calories and increased exercise
 No
specific tools or training provided for PCP
 PCP could recommend any weight loss strategy

Appointment 2 -5
 Discuss

Appointment 6
 Plan

any problems
for 6 month maintenance
1 Year follow-up
Results
60
40
20
0
-20
-40
N=
24
13
EC
MC
Insomnia
Goodie, J. L., Isler, W., Hunter, C. L., & Peterson, A. L. (2009). Using
behavioral health consultants to treat insomnia in primary care: a clinical
case series. Journal of Clinical Psychology, 65, 294-304.
Specialty Care Evidence

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Stimulus control
Sleep restriction
Sleep hygiene
Relaxation
Schutte-Rodin et al. (2008). J Clin Sleep Med. Morin et al., (1989). Sleep Research;
Morin et al., (1994), American Journal of Psychiatry.
Do CBT evidence-based treatments for
insomnia decrease insomnia
symptoms when delivered by a BHC in
primary care?
Methods

Case Control Series (Goodie et al. 2009)
 29
physician referred Primary Insomnia patients
 Limited
exclusion criteria
 Intervention
delivered by BHC
 Attend four appointments
 Assessment
(30 mins)
 1-2 intervention appointments (15-30 mins)
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Sleep hygiene, stimulus control, sleep restriction
Relaxation
Supplemental book
 Follow-up
Outcomes
Pre M (SD) Post M (SD)
SII
26 (4)
15 (5)
SOL (min)
49 (37)
24 (27)
WASO (min)
41 (32)
13 (11)
AVGWAK (min)
29 (36)
9 (7)
EMA (min)
20 (16)
9 (10)
TWT (min)
135 (50)
52 (38)
TST (min)
366 (113)
404 (97)
TIB (min)
499 (106) 459 (101)
SE
72 (13)
88 (10)
*Significant compared to α=.008; Goodie et al. (2009)
F
107*
17*
19*
9*
12*
95*
4
5
84*
η2
0.79
0.38
0.41
0.24
0.30
0.77
0.14
0.14
0.75
PTSD
Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen,
A. Peterson, A. L., and the STRONG STAR Consortium. (2011). Treatment of activeduty military with PTSD in primary care: Early findings. Psychological Services 8(2),
104-113.
Specialty Care Evidence

PTSD Treatment
 Prolonged
exposure
 Cognitive processing therapy
Powers et al. (2010). Clinical Psychology Review 30(6): 635-641.; Cloitre,
M. (2009). CNS Spectr 14(1 Suppl 1): 32-43.
Do CBT evidence-based treatments for
PTSD decrease PTSD symptoms
when delivered by a BHC in primary
care?
Intervention
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Adapted forms of prolonged exposure and
cognitive processing therapy
Assessed and treated by BHC
After initial assessment,
1
to 4 (up to 6) < 30 min appointments
 Weekly
 Homework between meetings
Procedures
Pt referred to BHC
Appointment 0
Testing
Appointment 1
Appointments 2-4
6 & 12 month Testing
Appointment 0
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Duration: thirty-minute appts
Brief Assessment (PCL-M)
Education
 Normal
recovery curve; “getting stuck”
 Role of avoidance in maintaining symptoms
 Evidence for exposure-based treatments

Presentation of treatment options
 Primary
care vs Specialty care vs Self-care
Appointment 1

“Confronting Uncomfortable Memories” workbook
Write narrative of traumatic experience
 Answer cognitive/emotional processing questions


Prescribe as homework
Goal: 30 minutes write/review daily
 Self-monitor SUD’s


Problem-solve homework implementation
When/where of homework
 Barriers to completion

Appointments Two to Four
(optional 5, 6)

Discuss homework completion

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Review SUD’s
Read narrative out loud (at least once)
Read answers to processing questions out loud
Socratic dialogue on problematic beliefs
Re-assign writing assignment as homework
BHC has option of other CP questions
Encourage opportunities for in vivo exposure
% with PTSD Diagnosis (PSS-I)
% meeting PTSD Dx
95
87.5
85
75
65
55
47.5
45
48.4
41.3
35
Baseline
N=24
Post-tx
6-month
N=17
N=16
1-year
N=11
Overall Χ2=8.95, p=0.03; All time points different from baseline (p < .01)
PCL-M
Mean (SE) PCL-M Scores
60
55.3 (2.2)
55
50
45
42.4 (3.3)
41.7 (3.3)
40
39.3 (3.2)
35
Baseline
N=24
Post-tx
N=17
6-month
N=17
1-year
N=10
Overall F=6.51, p=0.002; All time points different from baseline (p < .003)
Overall considerations
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What determines evidence-based care?
What outcomes should we expect?
Who can provide the evidence-based care?
Challenges with research in primary care
Questions

Jeffrey L. Goodie, LCDR, USPHS
Uniformed Services University
(301) 295-9461
[email protected]
Session #
October __, 2011
0:00 AM
Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and
Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes
HELEN L. COONS, PH.D., ABPP
PRESIDENT AND CLINICAL DIRECTOR
WOMEN’S MENTAL HEALTH ASSOCIATES
PHILADELPHIA, PA 19103
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
I have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
What is the scientific basis for this talk?
The presentation provides examples of evidenced based care
in collaborative obstetrics and gynecology and oncology
settings to improve physical and psychosocial outcomes.
Research on depression in women; preparing them for
diagnostic and treatment procedures; and the important
benefits of exercise will be translated.
Objectives
1) List research based interventions to assess and treat
depression in women in collaborative ob/gyn and
oncology settings.
2) Summarize evidenced based rational for preparing
women for diagnostic and treatment procedures in
collaborative ob/gyn and oncology settings.
3) Translate research on aerobic exercise to improve
outcomes in collaborative ob/gyn and oncology settings.
Expected Outcome
What do you plan for this talk to change in the
participant’s practice?
1) Increased focus on applying evidenced based interventions
in collaborative primary care (i.e., ob/gyn) and oncology
settings.
2) Increased application of gender specific research to
improve outcomes in collaborative ob/gyn and oncology
settings.
Learning Assessment
A learning assessment is required for CE credit.
1) Providing evidenced based care can improve
health and psychosocial outcomes?
2) Actively preparing women for medical
procedures in collaborative ob/gyn and oncology
settings can improve health and psychological
outcomes?
3) List the improved physical, psychological and
cognitive outcomes associated with aerobic
exercise in ob/gyn and oncology settings?
Women’s Health and Mental Health
Improving Outcomes Using EBP
Collaborative/Integrated Health Care Settings
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Primary Care Settings (IOM)
Internal and Family Medicine
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Pediatrics
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Geriatric Medicine
Adolescent Medicine
Obstetrics and Gynecology
Specialty Care Settings
Oncology
Surgery
Cardiology
Neurology
Endocrinology
PMR
Other
Evidenced Based Care
In Ob/Gyn and Oncology Settings
Clinical Research
 Depression in Women
 Preparing for Dx and Tx Procedures
 Exercise
 Assessment Treatment Prevention
Costs of Depression
Patient and family
 Quality of life, loss of hope,
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resilience
Functioning (days of disability,
quality of work)
Poor self-care
Adherence to treatment
recommendations
Risk/Co-morbidity for other health
conditions
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Obesity
Cardiovascular disease
Pain
Medications
 Impact on children and other
relationships
Health Care System
 Health care system

Increased Utilization
 Only 50% of adults with depression
are getting treatment from a health
professional
 Less than half (47%) of adults who
get treatment receive minimally
adequate care
WHO Report (1996), JAMA (2003)
Depression in Ob/Gyn Settings
General Factors
Specific
 Depression rates in
 Pregnancy Related
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women
Trauma
Caregiver issues
Chronic stress
Sleep deprivation
Inadequate support
SES
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Depression
Anxiety
Loss in any trimester
Infertility
Complications
 Gyn chronic conditions
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Pelvic
ICS
Vulvar diseases
Women with Depression in Ob/Gyn Settings
Inadequate care
 Not evidence based/informed
 Partial symptom reduction without full resolution of depression
 Failure to address underlying issues
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Misdiagnosis of medical disorder
Medication complications
Gender issues in etiology, assessment, treatment or prevention strategies
Poor sleep quantity and quality
Cognitive style
Trauma history
Failure to minimize risk for relapse or prevention

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patient
future generations
Active Application of Cognitive Treatment
 Reduce and then resolve depressive symptomatology and
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
anxiety
Markedly improve sleep
Calmer, more intentional response to host of issues with
less catastrophizing, over-personalization, etc.
Earlier recognition when negative or ruminative
cognitive style is present
More aware of how cognitive style impacts children
Specific strategies to reduce risk recurrent depression
Improve over-all well-being for the long haul
Evidenced Base Care in Oncology
Breast Cancer
 One in 8 life time risk
 Second most common cause of cancer death after lung cancer
 Over 192,370 new cases dx annually in the USA
 40,610 women die annually in USA
 Long term survival rate for early breast cancer has improved with new therapies –
especially in younger women
 Prevalence rate is 2,533, 193 – survivors!
 Chronic disease model focused in enhancing quality of well-being and reducing impact of
late effects of cancer and its treatment
ACS 2010 FACTS AND FIGURES
Depression in Women with Breast Cancer
 Women highly resilient
 Depression rates roughly 20% to 25%
 CBT
 Medications
 Tamoxifen metabolism and antidepressants
• Jin et al (2005) J Natl Cancer Inst.
Preparing Women for Diagnostic and Treatment
Procedures in Collaborative Medical Settings
 Preparing women for initial and late issues
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Physical
Cognitive
Emotional
Sexual
Relationships
Employment and professional
Genetic risk across family
Health and life insurance
 Preparing women for challenges across disease
course
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Different trimesters
Disease recurrence
Advanced and end-stage disease
Potentially Difficult Exams/Procedures
in Ob/Gyn Settings
 Breast exam
 Gyn procedures
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Pelvic exam
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Pelvic ultrasound
Colposcopy
Endometrial biopsy
HSG
Hysteroscopy
IVF procedures
Dx. laps
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 Cystoscopy/Urodyamics
 GI procedures
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Abdominal exam
Rectal exam
Endoscopy
Colonoscopy
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Venipunctures
Anesthesia
Oral or dental exam
Childbirth: Vaginal or C-section
Any type of biopsy and surgery
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Hysterectomy
Sterotatic core biopsy/needle loc
Sentinel node biopsy
Lumpectomy
Mastectomy
Reconstructive surgery
Breast reduction
Cancer surgery – colon/pelvic ext.
 Chemotherapy and Radiation
 MRI, Cat Scan, etc.
 Cardiac procedures
Preparing Women for Breast Cancer
Medical Procedures
 Diagnostic
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Mammograms
MRI
Ultrasound guided core biopsies
Stereotactic core biopsies
Needle localizations
Dye Injection for Sentinel Node
Biopsy
 Surgical
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Lumpectomy
Mastectomy
Reconstruction – several types
 Treatment
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Chemotherapy
Radiation
Hormonal
 Palliative
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Chemotherapy
Shunt
Nerve blocks
 Preventive
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
Mastectomies
TAB, LAVH with BSO
Actively Use Evidenced Based Practice
to Prepare Women for Procedures
Provide accurate information about cancer and its treatments
Assess patients/families fears and hopes
Facilitate decision making about procedures
Ask important questions, get second opinions
Make decisions they will trust and not regret
Mobilize informational, practical, social, and esteem support
Help to pace the patient
Decrease pain, bracing, and physiological reactivity
Reduce anxiety and fatigue
Increase feelings of self-efficacy, control and quality of life
Encourage patients to be active participants in their recovery and
healing
o Impact time to recurrence and survival?
o
o
o
o
o
o
o
o
o
o
o
Benefits of Regular Exercise
in Ob/Gyn and Oncology
General
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Improves self esteem with sense of
accomplishment
Improve body image
Improved cardiovascular fitness
Reduce muscle discomfort
Increase strength, flexibility, coordination
Decreased risk for diabetes
Weight control
Weight bearing exercise to build bone and joint
strength
Reduced risks for falls
Improve sleep
Reduce hot flashes
Reduce depression and anxiety
Helps with cognitive functioning
Improves sexual energy
Improves intimate relationships
Improved Quality of Life
Improve immune function
Improves post-surgical healing
Ob/Gyn and Oncology
Ob/gyn
Sleep
 Perinatal anxiety and depression
 Improved pregnancy outcomes
 Post partum anxiety, depression, energy,
wt management, body image

Oncology
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Manage treatment side effects
Increase energy, stamina
Lymphedema symptoms
Reduced risk of recurrence in ER+ breast
cancers or general mortality
EBC in Women’s Primary Care and Oncology
 Improve health outcomes
 Improve mental health outcomes
 Women’s well being!
Feel free to contact us
Barbara Walker
[email protected]
Jeffrey L. Goodie
[email protected]
Helen L. Coons
[email protected]
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!