Post on 24-May-2015
Evidence-Based Practice
Lunchbijeenkomst
14 maart 2013
HBO Universiteit
Post Grad
(E)MBA
Business Schools
1. Wat moet een student in de praktijk straks kunnen:
- zelf onderzoek doen?
- onderzoek kunnen beoordelen + toepassen?
2. Wat betekent dat voor het curriculum?
3. Wat betekent dat voor de accreditatie?
Aanleiding
“In onze moderne samenleving is het cruciaal dat hbo-
bachelors over een onderzoekend vermogen beschikken
dat leidt tot reflectie, tot evidence-based practice, en tot
innovatie.”
HBO standaard (2009)
Evidence-Based Practice ?
Wat is het?
Waar komt het vandaan?
Hoe ziet het er uit in een opleiding?
Hoe zit dat bij 4e jaars studenten?
Evidence based practice:
Wat is het?
Uitgangspunt bij evidence-based practice is dat beslissingen gebaseerd dienen te zijn op een combinatie van wetenschappelijk denken en de best beschikbare 'evidence'.
Evidence-based practice
Met het begrip 'evidence' wordt niet meer bedoeld dan 'informatie'.
Dit kan informatie zijn afkomstig uit wetenschappelijk onderzoek, maar ook interne bedrijfsinformatie en zelfs persoonlijke ervaring geldt als 'evidence’.
Evidence based practice
In principe neemt iedere manager dus beslissingen op basis van 'evidence'.
De meeste managers besteden echter nauwelijks aandacht aan de kwaliteit van de 'evidence' waarop ze hun beslissingen baseren.
Evidence based practice
Evidence-based practice:
kritisch en wetenschappelijk denken
van verschillende informatiebronnen gebruik maken
de beschikbare evidence kritisch tegen het licht houden
denken in termen van waarschijnlijkheid in plaats van 'golden bullets'.
Professional expertise and judgement
Best available organizational
evidence
Stakeholders’ values and concerns
Best available scientific evidence
Evidence-based decision
Evidence based practice
Evidence based practice:
Waar komt het vandaan?
“there is a large research-user gap”
“practitioners do not read academic journals”
“the findings of research into what is an effective intervention
are not being translated into actual practice”
“academics not practitioners are driving the research agenda”
“the relevance, quality and applicability of research is
questionable”
“practice is being driven more by fads and fashions than
research”
“many practices are doing more harm than good”
What field is this?
McMaster University Medical School, Canada
Medicine: Founding fathers
David Sackett Gordon Guyatt
How it all started
if you’re hyperventilating
breathe into a bag
Problem I: persistent convictions
elderly people who have an irregular heartbeat are much more likely to die of
coronary disease
give them a drug that reduces the number of
irregular beats
Problem I: persistent convictions
How 40,000 cardiologists can be wrong
In the early 1980s newly introduced anti-arrhythmic drugs were found to be
highly successful at suppressing arrhythmias.
Not until a RCT was performed was it realized that, although these drugs suppressed arrhythmias, they actually increased mortality.
By the time the results of this trial were published, at least 100,000 such patients had been taking these drugs.
David Sackett
Half of what you learn in medical school will be
shown to be either dead wrong or out-of-date
within 5 years of your graduation; the trouble is that
nobody can tell you which half.
The most important thing to learn is how to learn
on your own: search for the evidence!
(Remember that your teachers are as full of bullshit
as your parents)
More than 1 million articles in 40,000 medical journals per
year (= 1995; now probably more than 2 million). For a
specialist to keep up this means reading 25 articles every
day (for a GP more than 100!)
Problem II: too much information
Problem II: too much information
HRM: 1,350 articles in 2010 (ABI/INFORM). For an HR
manager to keep up this means reading 3 to 4 articles
every day (for a ‘general’ manager more than 50!)
BTW: most of the research is seriously
flawed or irrelevant for practice
The 5 steps EBP
1. Formulate a focused question (Ask)
2. Search for the best available evidence (Acquire)
3. Critically appraise the evidence (Appraise)
4. Integrate the evidence with your professional
expertise and apply (Apply)
5. Monitor the outcome (Assess)
Zelf onderzoek doen?
Evidence-Based Practice
1991Medicine
1998Education
1999Social care, public policy
2000Nursing
2000Criminal justice
????Management?
Evidence based practice:
Hoe ziet het er uit in de opleiding?
Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken
Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek.
Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal)
Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)
Evidence-based practice
Professional expertise and judgment
Best available organizational
evidence
Stakeholders’ values and concerns
Best available scientific evidence
Evidence-based decision
Evidence based practice
Waarom (wetenschappelijk) onderzoek?
Trust me, 20 years of experience
Bounded rationality
“The first principle is that you must not fool yourself - and you are the easiest person to fool”.
Richard Feynman
Bounded rationality
Het feilbare brein
System 1
Snel, actie Intuitief, associatief shortcuts & biasses
System 2
Langzaam (lui!) Rationeel Nadenken
Systeem 1
Seeing order in randomness Mental corner cutting Misinterpretation of incomplete data Halo effect False consensus effect Group think Self serving bias Sunk cost fallacy Cognitive dissonance reduction
Confirmation bias Authority bias Small numbers fallacy In-group bias Recall bias Anchoring bias Inaccurate covariation detection Distortions due to plausibility
Systeem 1: het feilbare brein
Het feilbare brein- Meningen
- Assumpties (aannames)
- Overtuigingen
- Persoonlijke ervaringen
Wetenschappelijk onderzoek- Feiten
- Evidence: bewijs / aanwijzingen
Waarom onderzoek?
BIAS
1. Denkfouten
2. Informatiebronnen
3. Mythbusting
4. Assumpties
Fase 1: Kritisch & wetenschappelijk denken
1. Seeing order in randomness
2. Confirmation bias
3. Small numbers fallacy
4. Outcome bias
5. Halo effect
6. Authority bias
7. Group think
7 Denkfouten (die u beter aan anderen kunt overlaten)
Een Type I fout of een vals positief: denken dat er een patroon / verband is terwijl dat er in het echt niet is.
Een Type II fout of een vals negatief: denken dat er geen patroon / verband is terwijl dat er in het echt wel is
Dr. Michael Shermer (Director of the Skeptics Society)
Seeing order in randomness
Een Type I fout of een vals positief: denken dat het geritsel in de bosjes een gevaarlijk roofdier is, terwijl het gewoon de wind is (goedkoop foutje)
Het feilbare brein: patern recognition
Een Type II fout of een vals negatief: denken dat het geritsel in de bosjes gewoon de wind is, terwijl het een gevaarlijk roofdier is (duur foutje)
Het feilbare brein: patern recognition
Het probleem met patroon herkenning:
Het kritisch beoordelen of er sprake is van een
Type I of een Type II fout is best moeilijk,
(vooral in ‘split second life and death’ situaties),
dus de default positie is om aan te nemen dat
alle patronen echt zijn.
Het feilbare brein: patern recognition
Een Type I fout of een vals positief: denken dat het geritsel in de bosjes een gevaarlijk roofdier is, terwijl het gewoon de wind is (goedkoop foutje)
DEFAULT
Een Type II fout of een vals negatief: denken dat het geritsel in de bosjes gewoon de wind is, terwijl het een gevaarlijk roofdier is (duur foutje)
Het feilbare brein: patern recognition
Ook ervaren mensen en experts zien patronen en verbanden waar ze niet zijn.
stress & lifestyle peptic ulcer
Het feilbare brein: patern recognition
Peptic ulcer – an infectious disease!
This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now
firmly established that Helicobacter pylori causes more then 90% of duodenal ulcers. The link between Helicobacter pylori infection and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Oct 2005
Ook slimme mensen houden er verkeerde ideeën op
na, niet omdat ze dom of eigenwijs zijn, maar omdat het
de meest logische conclusie is op basis van hun eigen
ervaringen.
Het feilbare brein: patern recognition
(systeem 1 doet altijd mee!)
Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken
Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek.
Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal)
Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)
Evidence-based practice
5-step approach
EBMgt is a 5-step approach
1. Formulate an answerable question (PICOC)
2. Search for the best available evidence
3. Critically appraise the quality of the found
evidence
4. Integrate the evidence with managerial
expertise and organizational concerns and apply
5. Monitor and evaluate the results
Formulate a focused question
Focused question?
Does team-building work?
What are the costs and benefits of self-steering teams?
What are the success factors for culture change?
Does management development improve the
performance of managers?
Does employee participation prevent resistance to
change?
How do employees feel about 360 degree feedback?
What is a ‘team’?
What kind of teams?
In what contexts/settings?
What counts as ‘team-building’?
What does ‘work’ mean?
What outcomes are relevant?
Over what time periods?
Foreground question?
Does team-building work?
P = Population
I = Intervention or success factor
C = Comparison
O = Outcome
C = Context
Answerable question: PICOC
2. Finding the best available evidence
Searching evidence
What do we search?
Current Information
Overview of a subject
General background
Academic Information
Statistical Information
Theories about a subject
What do we search?
Company information
Peer reviewed journals
Searching evidence
Where do we search?
Searching for evidence
Databases
ABI/INFORM
Business Source Elite
PsycINFO
Web of Knowledge
ERIC
Google Scholar
Searching for evidence
Searching evidence
How do we search?
Search Strategy
Two types of search strategies
Search strategy
Building blocks methodSnowball method
Search strategy
Search in ABI/Inform:
1. How many articles has Stephen Covey published in peer reviewed journals?
2. How many of these articles are based on scientific research?
3. Are there articles (by other authors) that are critical of Covey’s 7 Habits?
4. How many of these critical articles are based on scientific research?
Exercise: Search for evidence
Search in ABI/Inform or BSE:
Search for peer reviewed research articles to answer the following question: What is the long term effect of a hostile take-over on the financial performance of the acquired organization? Use the following search terms:
“hostile takeovers”, “financial performance”, “long term”
How many studies did you find?
Exercise: Search for evidence
Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken
Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek.
Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal)
Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)
Evidence-based practice
Which design for which question?
Research designs
Randomized controlled study? Grounded theory approach? Cohort / panel study? Qualitative field research? Longitudinal study? Post-test only study? Survey? Action research? Case study?
What is the best design?
What is the BEST car?
What is the best design?
quants vs quallies, positivists vs post structuralist, etc
on the research question
Effect vs Non-effect
Types of questions
Does it work?
Does it work better than ....?
Does it have an effect on ....?
What is the success factor for ....?
What is required to make it work ...?
Will it do more good than harm?
Effect
Types of questions: non-effect
Needs: What do people want or need?
Attitude: What do people think or feel?
Experience: What are peoples’ experiences?
Prevalence: How many / often do people / organizations ...?
Procedure: How can we implement ...?
Process: How does it work?
Explanation: Why does it work?
Economics: How much does it cost?
Internal validity
internal validity = indicates to what extent the
results of the research may be biased and is thus
a comment on the degree to which alternative
explanations for the outcome found are possible.
Internal validity
We are pattern seeking primates:
we are predisposed to see order
and causal relations in the world
Causal relations
1. Are the "cause" and the "effect” related?
2. Does the "cause" precede the "effect" in time?
3. Are there no plausible alternative explanations for the
observed effect?
effect size
before and after measurement
randomization, blinding, control group, measurements
Considerations for research:
Causality
Bias & Confounding
Research shows:
Shoe size > quality of handwriting
Smoking youngsters > better lung function
Levels of internal validity
Explanation
Which design for which question?
Different types of research questions
require different types of research designs,
but ...
Best research design?
But 1: feasibility
But 1: feasibility
Step 3: Critical appraisal of studies
Intermezzo
How to read a research article?
Critical appraisal: quick and dirty
Is the study design appropriate to the stated aims?
Are the measurements likely to be valid and reliable?
Was there a relevant effect size?
Is the outcome (population, type of organization)
generalizable to your situation?
Levels of internal validity
1. Were there enough subjects in the study?
2. Was a control group used?
3. Were the subjects randomly assigned?
4. Was a pretest used?
5. Was the study started prior to the intervention or event?
6. Was the outcome measured in an objective and reliable way?
6x yes = very high (A)
5x yes = high (A)
4-3x yes = limited (B)
2x yes = low (C)
1-0x yes = very low (D)
Appraisal
Critical appraisal questionnaires
www.cebma.org/ebp-tools
CAT: Critically Appraised Topic
CAT: Critically Appraised Topic
A critically appraised topic (or CAT) is a structured, short (3
pages max) summary of evidence on a topic of interest,
usually focused around a practical problem or question. A CAT
is like a “quick and dirty” version of a systematic review,
summarizing the best available research evidence on a topic.
Usually more than one study is included in a CAT.
CAT: structure
1) Background / context
2) Question (PICOC)
3) Search strategy
4) Results / evidence summary
5) Findings
6) Limitations
7) Recommendation
CAT-walk