By C.A Wolski
Since 1991, the American Speech-Language-Hearing Association (ASHA), the American Occupational Therapy Association (AOTA), and the American Physical Therapy Association (APTA) have worked together under the umbrella of the Tri-Alliance of Health and Rehabilitation Professionals to spread new ideas and practices. “It’s an effort on the part of these three organizations to have an opportunity to work together to address issues of mutual concern,” says Arlene A. Pietranton, PhD, CCC-SLP, chief staff officer for speech-language pathology at ASHA. “By working together on these issues, the Tri-Alliance represents the largest constituency of health and rehabilitation professionals in the areas of occupational therapy, physical therapy, audiology, and speech-language pathology. Collectively, the three organizations bring together close to 200,000 members.” This year the group is focusing on the importance of evidence-based practice, a subject often neglected in the rehabilitation world.
THE ALLIANCE
From left: Marc Goldstein, EdD; Deborah Lieberman, MHSA, OTR/L, FAOTA; and Arlene A. Pietranton, PhD, CCC-SLP
Consisting of the leadership of each organization, the Tri-Alliance serves its constituent memberships in several ways. It supports and promotes activities that are in the interest of the public; serves as a forum, resource, and advocate for public policy issues related to health, rehabilitation, and education; provides an arena to explore and communicate interprofessional issues; and provides and promotes joint educational opportunities. Working together benefits the three organizations.
“It gives the opportunity for the organizations to understand each other’s perspectives on an issue, and when the interests are in alignment, it gives us more potential impact by pooling our resources and more clout when we go to external audiences, whether they’re on [Capitol] Hill or at [the Centers for Medicare & Medicaid Services], to be able to say we’re representing 200,000 practitioners,” says Pietranton. The chairmanship of the organization rotates yearly between the executive directors of each organization. This year it is held by Ben F. Massey, Jr, PT, president of APTA.
This year’s theme of evidence-based practice will be a focus of each association’s professional meetings. Though the goal is the same, each association’s methods of reaching it are a little different.
FILLING THE VOID
Though considered a standard by both clinicians and payors, there is a lack of evidence-based practice in the rehab field. “Though increasingly considered a standard by both clinicians and payors, the reality is that there currently is a limited body of rigorous evidence, ie, research findings, related to clinical practice in all clinical fields. Some estimates are that as little as 20% of clinical practice in any field—medicine, nursing, rehab—can currently be supported by research findings. So the challenge is really twofold: clinical practitioners need to use the best evidence available to guide their clinical decisions. Wherever possible, this should be based on solid research findings; however, given our present body of clinical evidence, at times the best evidence currently available may in fact be expert opinion. And clinical disciplines need to assure that rigorous clinical research is done to build up the body of research-based evidence to close the 80% gap,” says Pietranton. “Back in 1999, there was an article that concluded as much as 80% of health care practice has yet to be validated by randomized clinical trials. In evidence-based practice, there are levels of evidence and the higher levels of evidence are the pure or more rigorous forms of research studies. One of the limitations of using evidence-based practice is that in some cases, you’re not going to find research to guide what you should or shouldn’t do. Sometimes you have to go with lesser degrees of evidence. You might have to go from published research studies that were from projects with trials where people weren’t randomly assigned to one study scenario or another, or you might have to go from published research findings that are based on case studies. One of the driving factors pushing the use of evidence-based practice is the cost-containment perspective. But there needs to be some wiggle room because we don’t yet have sufficient research in all areas to determine what is and what isn’t the most effective.”
One of the challenges of using evidence-based practice is determining what is best evidence. “There are two types of grading scales in this topical area,” says Pietranton. “One is the notion of levels of evidence—what level of scientific rigor and research design is associated with the study that was done? The other grading scale is on the strength of the recommendation. It uses an A,B,C,D,E classification—A is that there is good evidence to consider it; B is that there’s fair evidence to consider it; C might be that there’s poor evidence as to whether to consider it or not, it’s somewhat neutral; D might be fair evidence to not consider doing something; and E might be there’s good evidence to not consider doing something.” Pietranton adds that the Agency for Healthcare Research and Quality recently added a new classification—I—for insufficient evidence to make a recommendation.
Each association is responsible for its own evidence-based practice project, which varies in scope and member involvement.
OUTCOMES MEASUREMENT SYSTEM
ASHA’s project is the establishment of a national outcomes measurement system (NOMS). “It consists of a number of functional communication measures, and it allows us to be able to look at patients’ status at the time of admission and their status at the time of discharge and determine whether there are measurable changes in their functional communication between admission and discharge,” says Pietranton. “We want to encourage researchers in the field of human communication and communication disorders to use research design that will yield the highest possible level of evidence.”
Data are being collected by “a moderate level” of ASHA’s 107,000 members who have been positive in their feedback. “Among those who have been involved with the project, it’s been very positive,” says Pietranton. “And members in general have appreciated the questions that can be answered through the outcomes system. We definitely need to get more members involved in collecting data and using data.” ASHA has been collecting data for the past 5 years, and now has a database of 50,000 patients.
Members are recruited to collect data via ASHA’s Web site, meetings, and newsletter. The data are collected and a report is issued quarterly. “If you’re a subscriber to the ASHA NOMS then you get reports…and it benchmarks your program in terms of the outcomes you get with different groupings of patients in contrast to other similar programs,” says Pietranton. “We also generate report cards and those are on the Web. The information from NOMS is being used for advocacy purposes with administrative and policy issues, so it can help make decisions about caseload size and staffing levels. It can be used with payors in terms of the amount of treatment that’s needed to achieve the kinds of benefits or gains that are helpful to patients. It can also be used in terms of developing research questions. And it can be used with patients also.”
Concurrent with collecting data is ASHA’s marketing of the evidence-based practice idea. This is being done at conference sessions, through articles, and in face-to-face contact. The campaign is aimed at members, nonmembers, and students.
LITERATURE REVIEW
For AOTA, the time is right for promoting evidence-based practice. “I think it’s definitely a buzzword in health care delivery and financing today, so, from that perspective, the interest and need to have evidence to support clinical and coverage decisions are there,” says Deborah Lieberman, MHSA, OTR/L, FAOTA, practice associate at AOTA. “It’s an important challenge for occupational therapy as a profession. I think people, as individual providers, are asking the questions in order to provide high-quality patient care and to have quality information on which to base clinical and managerial decisions. So these issues point to the need for the practice to be based on available evidence. The mention of evidence-based practice very much brings out different reactions from rehabilitation practitioners. The whole concept seems to be sometimes very daunting in terms of finding applicable evidence and evaluating it and then how to put the recommendations into practice. And the fact is, practice is not solely based on the evidence, but really on the combination of…science as well as the art of providing patient care.” One of the reasons evidence-based practice has not been the norm in occupational therapy is because of the difficulty in collecting the necessary data. “It’s hard in rehabilitation to conduct the kind of randomized, controlled trials for ethical and other reasons. Therefore, in rehabilitation, we don’t necessarily have the same kind of models that you may have in terms of medicine or drug studies,” says Lieberman.
AOTA’s project centers around an evidence-based practice literature review, a project that predates the Tri-Alliance focus. Initial feasibility and pilot studies were done in 1998 and 1999. As with ASHA, the AOTA membership has been recruited to help with the project. “Even though this project is being done by AOTA, it has benefited from the help and assistance of our members and we’ve just been fortunate to have a lot of participation, assistance, and advice from very knowledgeable occupational therapists and people outside the profession as we’ve gone along,” says Lieberman. “That has been a wonderful experience to be able to take advantage of people’s wealth of knowledge.”
The project is not just an academic exercise with no practical implications. “The goal of the project is to address the need of occupational therapists and occupational therapy assistants to have access to the scientific literature that is relevant to their practice and program development, in order to help them [make] practice care decisions,” says Lieberman. “Hopefully, this will become part of a practitioner’s milieu where they will continue to learn and evaluate their techniques based on what they’ve learned from the literature as well as clinical practice.”
Findings will be disseminated via AOTA’s Web site. “These Web briefs will provide access to summary information of the scientific articles that address the effectiveness of interventions used in occupational therapy practice,” says Lieberman. “It will describe the methods that we used, the findings from the articles, and also interpretive information—what the findings mean.”
Success will be measured by how many people access the findings on the Web site and how these findings are influencing clinical practice. The latter may be determined using a questionnaire or other type of follow-up.
HOOKED ON EVIDENCE
APTA’s project—Hooked on Evidence—is focused on giving PTs the essence of evidence-based research. “The very specific problem physical therapy has had is a disconnect between the researchers and the clinicians in the professions,” says Marc Goldstein, EdD, director of research services for APTA. “People who practice and have not been involved in research have always said they just don’t have the time to read the research literature, so there may be new interventions that are cited in the literature, the effectiveness may have been cited, but the typical clinician, because the caseload is so great, can’t read journal articles.”
Hooked on Evidence involves writing summaries of evidence-based articles and putting them into a database housed on APTA’s Web site. “It will become an online database of intervention literature, [which] will have a number of really neat outcomes,” says Goldstein. “But I think the most pragmatic [outcome], and what will help the most clinicians, is that through one or two clicks on a computer, they will be able to compare different interventions and see which one is more effective. If everything goes the way we have planned, it’s going to eliminate the excuse, ‘I don’t have time to read the literature and have to continue practicing in the same mode that I’ve been practicing in.’ Now, very quickly, without reading journal articles and without going into some other database that might be harder to access, the clinician, with a patient literally in the office, can make an assessment on which intervention is more effective. The goal is, generically, to enhance practice, and that enhancement will be brought about by the use of this database.”
Like the other associations, APTA is using members to gather data. “The extractions will be entered by a grassroots effort of physical therapists,” says Goldstein. “There is a standardized extraction form that…can be accessed by any member of APTA, and it [takes] 45 minutes to complete one of these extractions. What we’re asking for is something that’s relatively simple to do, a summary of what is stated in the article. There are some quantitative aspects of what we’re looking for, but more often than not, if these aspects haven’t been reported by the author, then the person entering the abstract really doesn’t have to worry about computing anything, so it becomes a nice vehicle for somebody who doesn’t have a lot of experience in research to get involved. It has created a great deal of enthusiasm among your typical physical therapists.”
APTA is promoting the program through mass mailings, advertisements, and articles in the association magazine. But Goldstein says the most effective method is person-to-person promotion at various meetings and conferences. “Even though we have, through print media, publicized the process really well, when we do the presentations, reaction is often, ‘This is really a fascinating project and how come I didn’t know about it before?’” he says.
And while the evidence-based practice theme will be the official focus of the Tri-Alliance only for this year, each association plans to continue its efforts to promote this idea into the foreseeable future. “This is a very long-term project,” says Goldstein.
Next year’s theme—future trends and issues in clinical practice, clinical education, and public policy—has already been determined, and, because it is a future trend, may continue to include evidence-based practice in its agenda.
