Home Advocacy Call for Advocacy to Garner Government Support for Evidence-Based Treatments

Call for Advocacy to Garner Government Support for Evidence-Based Treatments

by Leanne Togher

Editor’s Note: This post is another viewpoint on the Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Evidence-based practice encompasses evidence from high-level research, expert opinion, patient needs and values, along with the context within which the treatment is conducted. In the field of stuttering, we are fortunate to have strong evidence that the Lidcombe Program is effective. If we have clear evidence that a treatment approach works, it should be made available to the people who need it.

Speech Pathology Australia has made a submission to our [Australia’s] federal government to fund stuttering treatment. I’m sure it will be the first of many submissions, which aim to bridge the evidence-practice gap. However, there appears to have been a misunderstanding about the announcement, so SPA published a clarification on its website stating that “SPA’s submission relates only to the formation of the 2015-2016 federal budget. SPA is not supporting legislation or a policy change to promote one program, service or form of treatment over any other.”

As a founder of the speechBITE evidence-based practice website, I thought long and hard about the effect EBP has on clinical practice, funding sources and, most importantly, the clinical outcomes of the people we serve. There are three key aspects to making EBP a central component of clinical decision-making:

  • Firstly, clinicians need to know about the latest treatment advances.
  • Secondly, patients and clients need to be informed about current best practice options, and be satisfied with their treatment decision.
  • Thirdly, funding agencies need to be confident that they are funding treatments that are based on strong evidence.

How can funding agencies be aware of current best practice and confident in their funding decisions? As a profession we need to be proactive by giving this information to funding agencies and lobbying the government. This is precisely what SPA is doing with its proposal. I applaud SPA for taking this step and promoting evidence-based speech pathology practice at the highest level.

 

Leanne Togher, PhD, SLP, is a professor of communication disorders following traumatic brain injury at The University of Sydney and is Senior National Health and Medical Research Council Fellow of Australia. Togher is the director of the speechBITE evidence-based practice website. She is also an international affiliate of ASHA and Fellow of Speech Pathology Australia. She can be reached at Leanne.togher@sydney.edu.au.

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22 comments

Joseph S. Attanasio March 17, 2015 - 11:52 am

Thank you, Dr. Togher, for your cogent statement. One source of confusion, I believe, is that critics of Speech Pathology Australia’s proposal suggest that Lidcombe has been selected because it has the most evidence supporting it while they maintain other approaches also have evidence, perhaps not as much as Lidcombe’s, but evidence nonetheless. Although that may be true, what is left out of the equation is that Lidcombe has the highest levels of what is accepted as evidence for efficacy and effectiveness. The research methodologies of the studies of non-Lidcombe approaches are simply not as strong as the methodologies used in recent studies of Lidcombe; hence, the levels of evidence for those other approaches are not as high.

Brooke Leiman March 17, 2015 - 1:51 pm

Joseph- I don’t believe anyone is confused about the information you stated in regards to efficacy and evidence. We can all agree that Lidcombe has the “most” evidence, although many clinicians would argue not the “best” evidence. Perhaps a response to the concerns that Craig brought up in his original post would be helpful. The SPA’s response continues to be that they are not promoting one approach over another. However this statement does not address our concerns related to:
1. how this proposal is limiting the clinicians ability to individualize treatment (yes- they can choose the approach they use but at the risk of not getting paid)
2. how this proposal is ignoring the other pillars of evidence-based practice (client/family values and clinician’s expertise)
3. how this proposal will impact funding of future stuttering research.

We’ve also yet to receive feedback on Craig’s idea that instead of fighting for reimbursement for one treatment program over another, we instead fight to receive reimbursement for early intervention for stuttering treatment. If we can get responses to these questions (as well as many other questions that have been posed on ASHAsphere, community forums, etc.), we may be able to move forward.

Corrin Richels March 17, 2015 - 1:56 pm

Part of the argument remains that the scientific evidence is only one piece of the evidence-based practice decision tree. There are two other equally important factors including the needs of the person you are treating and his/her family, and the skills and training of the treating clinician.

Please see the equally cogent press release from International Fluency Association :

http://www.theifa.org/

Brooke Leiman March 17, 2015 - 2:12 pm

Well said Corrin. I would also urge speech pathologists to read the Stuttering Foundation’s statement: http://www.stutteringhelp.org/content/another-blunder-down-under-0

Joseph S. Attanasio March 17, 2015 - 3:19 pm

Brooke,

What, in your opinion, constitutes best level or highest level of evidence?

Brooke Leiman March 17, 2015 - 10:22 pm

I think we are talking past each other. Leanne clearly states that evidence based practice is made up of “high-level research, expert opinion, patient needs and values, along with the context within which the treatment is conducted.” How you or I define the highest level of scientific research is neither here nor there (at least for this argument) because high-level scientific research is only one aspect of EBP. My concern is not whether the Lidcombe Program does or does not have a high level of scientific research. My concern is that while SPA is standing behind the fact that they promote EBP, their choice to promote one approach over another actually means they are taking 2/3 of EBP out of the equation (clinician experience and clients needs/values). Yes- Lidcombe program has randomized controlled trials which is is one source of evidence. However, clinicians need to consider other forms of evidence as well in order to say they are adhering to EBP. This proposal forces clinicians to decide between being reimbursed and using a diverse evidence base to determine their treatment plan.

Joseph S. Attanasio March 18, 2015 - 12:11 pm

I don’t believe that the proposal forces clinicians to decide between being reimbursed and using a diverse evidence base (I’m not sure what that means) to determine their treatment plan. Let us not forget the population for whom the LP was developed–early stuttering or preschoolers who stutter. Yes, there is some evidence that the LP works with somewhat older children. Australian clinicians will continue to use other treatment approaches for children beyond the ages covered by the LP and for adults who stutter, knowing that they will not be reimbursed. Let us also give our Australian colleagues credit for making the right choice when deciding on treatment plans for LP age children. I see nothing wrong with starting with the LP with those children and then switching if it turns out that it wasn’t appropriate for the particular child. I refuse to believe that clinicians will persist in using the wrong treatment, or even think about doing so, in order to collect money. If you read what the LP developers have written about LP and what is taught in their LP training workshops, you will learn that their first concern is to do no harm.

Katie Gore March 18, 2015 - 12:26 am

I agree with Brooke, and this statement from ASHA regarding the definition of EBP is a good reference: http://www.asha.org/members/ebp/intro/

“Because EBP is client/patient/family centered, a clinician’s task is to *interpret* best current evidence from systematic research in relation to an individual client/patient, including that individual’s preferences, environment, culture, and values regarding health and well-being. Ultimately, the goal of EBP is providing optimal clinical service to that client/patient on an *individual basis*.”

The individual is what comes first, not the amount of published research.

If you went to the doctor’s office and s/he prescribed you a medication, you might ask, “Doctor, is the best solution for me?” The doctor says, “Studies have shown this medicine is the most effective.” But what if something about that doesn’t sit right with you, and you follow with, “Yes, doctor, but I am not asking if it is ‘the best’. I am asking if it is the best FOR ME.”

Katie Gore March 18, 2015 - 12:41 am
Joseph S. Attanasio March 18, 2015 - 9:21 am

Here is a different interpretation:

ASHA states that “The term evidence-based practice refers to an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions.” That statement and its elaborations on the ASHA web site do not, as far as I can tell, suggest that the EBP triad of research evidence, clinical expertise, and client characteristics, values, and preferences form an equal partnership; that the three have equal force or standing. Rather, research is the primary component and the primary source of evidence. EBP, then, is the integration of research with practitioner expertise in the context of client preferences and values.

When the three components fit together, clinical decision making is facilitated. When the three do not mesh, clinical decision making becomes challenging and complicated.

You can see from the ASHA web site that the first step is framing the clinical question

Key Steps in the EBP Process

• Step 1: Framing the Clinical Question
• Step 2: Finding the Evidence
• Step 3: Assessing the Evidence
• Step 4: Making the Clinical Decision

If you will pardon a personal anecdote: When I became ill, after the examination and diagnosis, my physician outlined a treatment plan based on what medical research said was the most effective course to follow for that disease. Neither he nor I asked if this was the best treatment for ME; the decision was based on what was the best treatment for the DISEASE i had. The outcome? I was cured. Obviously, if there were contraindications in my medical history, a different, and perhaps less effective, course of treatment would have been followed.

Katie Gore March 18, 2015 - 5:53 pm

Interesting, your anecdote brings an entire other philosophical medical debate to mind (treating the person vs. the disease)! Too much for this thread. 🙂

Your story seems like it suits both sides here, in that it was the most scientifically effective treatment, and also the best in your doctor’s clinical expertise, and matched your values as a patient (you agreed it was a good path to take). Like you said, ideally all three things fit together. And, after all, the most effective treatments ARE going to be the best solution for *most* people *most* of the time– that is what makes them the most effective!

The big concern with this issue is, what if a family/child/client doesn’t fall into the “most people” category?

Your suggestion of the different weighting of evidences was interesting. I did find this on ASHA’s site: http://www.asha.org/CE/for-providers/Evidence-Based-Practice-CE-Providers/

“ASHA uses the following definition of EBP: the integration of research evidence with practitioner expertise and client preferences and values into the process of making clinical decisions. Note that although this is referred to as “evidence-based” practice, the roles of clinician expertise and client preferences and values are equally important. The notion that external research evidence somehow “trumps” all other considerations is one of the big myths surrounding EBP.”

Craig Coleman March 18, 2015 - 3:32 pm

If you look at the website on evidence developed by the author of this blog post, a study of the Lidcombe program is rated number 1 in quality of evidence in stuttering treatment. But if you search “autism,” the number one rated treatment study is…..acupuncture! Number 2 is hyperbaric chamber. And in case that were not enough, the drug Risperidone appears to be effective at treating both stuttering AND autism, as it ranks in the top five in each disorder.

Joseph S. Attanasio March 19, 2015 - 12:37 pm

Which blog?

Are you suggesting that the research on the Lidcombe Program is questionable given the reference to acupuncture in the treatment of autism on the same blog? I’m a bit confused by your reference.

Craig Coleman March 19, 2015 - 3:21 pm

I am not suggesting anything. I am stating that according to the author’s website (not blog) at SpeechBite, acupuncture and hyperbaric chamber for autism have the same rating as the Lidcombe studies. So what I am stating is that perhaps the way evidence is evaluated is a bit flawed.

Leanne Togher March 19, 2015 - 4:57 pm

speechBITE does not present a list of top rated treatments. It offers a critical appraisal of the methodological quality of treatment papers. Specifically, speechBITE provides ratings of methodological quality of group comparison papers – that is, it provides an indication of the risks of bias that may be inherent in group comparison studies, such as whether randomisation was completed, whether allocation was concealed, whether the groups were similar at baseline, whether blinding of participants, therapists and assessors occurred, whether there was more than 85% of data reported post treatment, whether intention to treat analysis was used, whether between groups statistical reporting occurred and finally, whether there was a report of the variability (such as reports of standard deviations, interquartile ranges). Each paper is scored by 2 independent raters using the PEDRo-P scale which comprises these elements. If there is disagreement in the rating a third rater provides consensus. speechBITE does not provide an indication of the “number one rated treatment”. We are clear that we are providing clinicians, students and researchers with a critical appraisal of the methodological quality of papers, that is the risks of bias that may be in treatment reports. This enables our users to determine the quality of the reporting, not the quality of the treatment.

Craig Coleman March 20, 2015 - 2:23 pm

I never said it presented top rated treatments. I said it presented ratings on treatment studies. And if the methodology yields results that indicate acupuncture and hyperbaric chamber are the top rated treatment studies for children with autism, then perhaps the methodology is flawed.

Leanne Togher March 20, 2015 - 9:41 pm

speechBITE (speechbite.com) assists SLPs with two key aspects of the EBP process, as shown in the diagram at the top of this blog, namely, searching the evidence and appraising the methodological quality of the evidence in a timely fashion. speechBITE presents PEDro scores which describe possible sources of bias that may have occurred in the reporting of a clinical trial. PEDro is NOT a measure of the validity of a study’s conclusions or whether that treatment is useful.

In those papers with very low PEDro scores, there are considerable sources of possible bias, which may bring the findings into question. For example, criterion 4 on the PEDro scale examines whether groups were comparable at baseline before a treatment is introduced. In the absence of reporting this information, we do not know whether improved performance by a treatment group at the completion of a clinical trial was because the treatment group were better to start with, or whether the treatment was efficacious. On speechBITE we list the score for each criterion of the PEDro scale to help clinicians appraise clinical trials and determine possible sources of bias. This information can inform the EBP decision-making process.

speechBITE lists all treatment studies relevant to speech pathology practice. A search generates a list of reports, whereby systematic reviews are listed first (as the highest level of evidence) followed by group comparison trials, case series, single case experimental designs and practice guidelines. Papers are included on speechBITE if they fulfil the following criteria:
1. The paper is published as a full-length paper (not an abstract) in a peer-reviewed scientific journal.
2. The population treated will have, or be at risk of, a communication disorder and/or dysphagia.
3. The treatment is currently part of speech pathology practice or could become part of speech pathology practice. The intervention need not be carried out by speech pathologists.
4. The trial includes evaluation of at least one intervention and includes empirical data regarding treatment efficacy (i.e. editorials, non-systematic reviews or case descriptions are not included).

Our monthly auto search of 9 databases (including Medline, PsychINFO, CINAHL etc) generates approximately 2000 papers. We read the abstracts of all 2000 papers, and determine which of these comply with the above criteria, which is usually 2-5% of papers. These papers are then indexed so that users can find them on our searchable database, and then group comparison studies are rated for their methodological quality. In line with other EBP databases, such as the physiotherapy database, PEDro, the occupational therapy database, OT Seeker and the database for behavioural treatments following acquired brain injury, PsycBITE, we rate the methodological quality of group comparison studies using the PEDro scale. The bibliographic details are then uploaded onto the database and links are provided to the abstract.

The aim of speechBITE is to assist speech pathology students, clinicians and researchers in the complex and challenging process of using EBP in an informed and timely manner. In 2014, speechBITE received over 4 million hits from over 150 countries. In addition to free access to the database, we have a free online tutorial (http://speechbite.com/rating-research-quality/outline-rating-training-program/) to enable people to learn how to use the PEDro scale.

Craig Coleman March 24, 2015 - 10:58 pm

I feel like we are talking about two different things here. I understand your process. Thank you for clarifying it. You say that SpeechBite doesn’t rate treatments, yet the very first statement on your website is “SpeechBite: Speech Pathology Database for Best Interventions and Treatment Efficacy.” Using the phrase “Database for best interventions” certainly implies you rate treatments. That is somewhat misleading given your statements above.

Additionally, you say “The aim of speechBITE is to assist speech pathology students, clinicians and researchers in the complex and challenging process of using EBP in an informed and timely manner.” EBP is not simply evaluating research articles, in any sense of the term. Are you evaluating clinical experience or client and family values? How about client-clinician relationships? If there answer is no, then this website is not really about EBP. It is about research ratings. That is a very different concept. You can’t discuss evidence-based PRACTICE in the context of only research, with no practice. I am not saying it is not valuable to some degree because it is, but please don’t confuse evidence-based practice with evaluating research evidence. Both have a place but they are not the same.

boboq March 18, 2015 - 5:34 pm

This is a frightening anecdote. My physician, who understands EBM and knows that I understand EPB, always asks me about MY CONDITIONS before prescribing any treatment. I would be quite uncomfortable if he simply decided on a treatment because group data suggested it was effective. My doctor and I always consider any treatment options in the context of my personal health history. If your doctor and you never “asked if this was the best treatment for [YOU]” I think that is a tragedy.

Joseph S. Attanasio March 19, 2015 - 12:20 pm

I believe I did write that if my medical history contraindicated the treatment, an alternative would have been introduced. Check again and don’t be frightened. My physicians all know of my history and review it each time I am in their offices. And of course, the ME (YOU) in all of this is as a member of the population for whom the treatment selected has been found to be the most effective through research and clinical practice.

Joseph S. Attanasio March 19, 2015 - 12:45 pm

I believe I did write that if my medical history contraindicated the treatment, an alternative would have been introduced. Check again and don’t be frightened. My physicians all know of my history and review it each time I am in their offices. And of course, the ME (YOU) in all of this is as a member of the population for whom the treatment selected has been found to be the most effective through research and clinical practice.

Leanne Togher March 25, 2015 - 6:43 pm

It is clearly stated on the speechBITE website that we are offering a service to help with two steps of the EBP process, namely steps 2 and 3. The 5 steps of EBP are neatly displayed in the diagram at the beginning of this blog. We clearly state on our website where speechBITE fits in to the process of EBP decision making as follows:

“How does speechBITE help in the EBP process?

speechBITE aims to reduce the time and challenges associated with accessing and appraising the research evidence in order to make EBP easier for all clinicians. We’ve done this by searching, indexing and rating the quality of 1000’s of treatment papers for you.”

That is, speechBITE offers a resource to assist with two aspects of the EBP process, accessing and critically appraising the evidence. It is erroneous to state that “it is not about EBP”.

speechBITE is freely available to clinicians to help them find published speech pathology evidence which they can then use in the process of determining the best treatment for their client. It was developed to inform the EBP decision making process, but of course research evidence is not the only component of EBP decision making and we make this clear on our website under the heading “What is EBP?” when we write:

“In other words, we need to know what the research says, share this knowledge in an unbiased way with our clients, and with those clients make decisions about care based on our evaluation.”

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