Evidence-Based Practice
in Continence Care
Assoc Prof Winsome St John RN PhD
Research Centre for Clinical Practice Innovation
School of Nursing and Midwifery, Griffith University, Gold
Coast
Quick review of evidence based
practice
Debates in evidence based practice
Overview of evidence for continence
Resources
Ways forward
History
Critique of medical practice
The Cochrane Collaboration
Actually, we don’t really
base all of the things we
do on good scientific
evidence
Evidence shows that
some things we have
‘always done’ can
even cause harm.
Evidence-based medicine
The conscientious, explicit and judicious use
of current best evidence in making the
decisions about the care of individual
patients. The practice of evidence based
medicine means integrating individual clinical
expertise with the best available external
clinical evidence from systematic research.
(Sackett et al, 1996, p. 249-254)
Evidence-based practice
The systematic interconnecting of
scientifically generated evidence with
the tacit knowledge of the expert
practitioner to achieve a change in a
particular practice for the benefit of a
well defined client / patient group.
French, 1999, p. 74
Evidence-Based Practice
Centres
Cochrane Collaboration
Joanna Briggs Institute (JBI)
Campbell Collaboration
Universities
Hospitals
Evidence-Based Journals
Why should clinicians think about
EBP?
Providing care based on research / evidence
will enable us to:
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Keep up to date – accurate information
Develop our body of knowledge
Provide a basis for clinical judgments & practice
guidelines
Provide high quality, cost effective care
Eliminate worst practice
Remain accountable
Validate and justify care, Lobby for resources
What is evidence?
How do you know what you know?
Types of information in the literature
Texts, secondary sources
 Descriptions
 Theoretical literature
 Single research studies
 Reviews of the literature
 Systematic reviews
 Meta-analyses

Weighing the Evidence
Not all research is well designed, valid,
generalisable
The evidence must be appropriate to
The question
 Practice issue
 Client group

Not all evidence is equal
Level
Intervention 1
I
A systematic review of level II
studies
II
A randomised controlled trial
III-1
A pseudorandomised controlled trial
(i.e. alternate allocation or some other method)
III-2
A comparative study with concurrent controls:
▪ Non-randomised, experimental trial
▪ Cohort study
▪ Case-control study
▪ Interrupted time series with a control group
III-3
A comparative study without concurrent controls:
▪ Historical control study
▪ Two or more single arm study
▪ Interrupted time series without a parallel control group
IV
Case series with either post-test or pre-test/post-test outcomes
NHMRC 2008 Evidence Hierarchy: designations of ‘levels of evidence’ according to type
of research question
Key Questions
1.
2.
3.
4.
5.
6.
Evidence base
Consistency
Clinical impact
Generalisability
Applicability
Other factors
NHMRC 2008
Critique of this Approach
to Weighing Evidence
RCT – effectiveness
Does not necessarily provide answers for
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Diagnosis, prognosis, harm
Patient decision-making, health behaviours, daily-living
management
Economic costs
Discounts other forms of evidence
How and why
Tightly controlled studies may not be widely generalisable
Study results may not take account of patient context
Judgments about when the evidence is relevant
JBI Applicability FAME Scale
Feasibility
evidence about the extent to which an activity or intervention
is practical.
Appropriateness
evidence about the extent to which an activity or intervention
is Ethical or culturally apt.
Meaningfulness
evidence about the personal opinions, experiences, values,
thoughts, beliefs or interpretations of clients and their families
or significant others.
Effectiveness
evidence about the effects of a specific intervention on
specific outcomes.
(JBI, 2008)
JBI Model of Evidence-Based Health Care 2008
JBI Levels of Evidence (2008)
Making Evidence Accessible to
Busy Clinicians
Systematic reviews
Summaries
Abstracts
Practice sheets
Evidence-based clinical guidelines
A Systematic Review is:
“… a review of a clearly formulated
question that uses systematic and
explicit methods to identify, select, and
critically appraise relevant research”
(Cochrane, 2005).
How are they done?
A systematic review
Has a focused clinical question, protocol
Based on research evidence – not authority,
opinion
Focuses on a client group, intervention, risk
factor
Examines benefits, harm, cost effectiveness
The search is exhaustive
Examines rigour of research
Includes consultations with clinicians
Weighs levels of evidence
When should a systematic
review be carried out?
The problem requires a response from
health professionals
There is a recurring practice problem
To investigate a common therapeutic
practice or approach
To develop standards or protocols
Recent research generates questions
about practice
Cochrane Library: Systematic Reviews
Exercises, Biofeedback & Electrical Stimulation
Physical therapies for prevention of urinary and faecal
incontinence in adults J Hay-Smith, P Herbison, S Mørkved 2007
Pelvic floor muscle training for urinary incontinence in women Jean
Hay-Smith, Kari Bo, Bary Berghmans, Erik Hendriks, Rob de Bie,
Ernst van Waalwijk van Doorn 2008
Pelvic floor muscle training versus no treatment, or inactive control
treatments, for urinary incontinence in women EJC Hay-Smith, C
Dumoulin 2006
Weighted vaginal cones for urinary incontinence P Herbison, N
Dean 2002
Pelvic floor muscle training for urinary incontinence in women Jean
Hay-Smith, Kari Bo, Bary Berghmans, Erik Hendriks, Rob de Bie,
Ernst van Waalwijk van Doorn 2008
Electrical stimulation with non-implanted electrodes for urinary
incontinence in adults Berghmans, K Bo, E Hendriks, M van
Kampen, R de Bie 2004
Neuromodulation with implanted electrodes for urinary storage and
voiding dysfunction in adults P Herbison, E Arnold 2003
Cochrane Library: Systematic Reviews
Bladder retraining & Voiding
Timed voiding for the management of urinary incontinence in adults J
Ostaszkiewicz, L Johnston, B Roe 2004
Habit retraining for the management of urinary incontinence in adults J
Ostaszkiewicz, T Chestney, B Roe 2004
Bladder training for urinary incontinence in adults SA Wallace, B Roe, K
Williams, M Palmer 2004
Pharmacological Intervention
Oestrogens for urinary incontinence in women B Moehrer, A Hextall, S
Jackson 2003
Adrenergic drugs for urinary incontinence in adults A Alhasso, CMA
Glazener, R Pickard, J N'Dow 2005
Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary
incontinence in adults P Mariappan, AA Alhasso, A Grant, JMO N'Dow 2005
Management
Catheter policies for management of long term voiding problems in adults
with neurogenic bladder disorders J Jamison, S Maguire, J McCann 2004
Absorbent products for light urinary incontinence in women M Fader, AM
Cottenden, K Getliffe 2007
Cochrane Library: Systematic Reviews
Client groups
Treatment of urinary incontinence after stroke in adults LH Thomas, S
Cross, J Barrett, B French, M Leathley, CJ Sutton, C Watkins 2008
Conservative management for postprostatectomy urinary incontinence KF
Hunter, KN Moore, CMA Glazener 2007
Behavioural and cognitive interventions with or without other treatments
for the management of faecal incontinence in children M Brazzelli, P
Griffiths 2006
Faecal Incontinence & Constipation
Behavioural and cognitive interventions with or without other treatments
for the management of faecal incontinence in children M Brazzelli, P
Griffiths 2006
Plugs for containing faecal incontinence M Deutekom, A Dobben 2005
Sacral nerve stimulation for faecal incontinence and constipation in adults
G Mowatt, C Glazener, M Jarrett 2007
Biofeedback and/or sphincter exercises for the treatment of faecal
incontinence in adults C Norton, JD Cody, G Hosker 2006
Drug treatment for faecal incontinence in adults Mark J Cheetham, Miriam
Brazzelli, Christine C Norton, Cathryn MA Glazener 2002
Electrical stimulation for faecal incontinence in adults G Hosker, JD Cody,
CC Norton 2007
Cochrane Library: Systematic Reviews
Investigations
Urodynamic investigations for management of urinary
incontinence in children and adults CMA Glazener, MC Lapitan
2002
Surgical Intervention
Surgical management of pelvic organ prolapse in women C Maher,
K Baessler, CMA Glazener, EJ Adams, S Hagen 2007
Open retropubic colposuspension for urinary incontinence in
women MC Lapitan, DJ Cody, AM Grant 2005
Surgery for faecal incontinence in adults SR Brown, RL Nelson
2007
Traditional suburethral sling operations for urinary incontinence
in women CA Bezerra, H Bruschini, DJ Cody 2005
Minimally invasive sling operations for stress urinary
incontinence in women CCB Bezerra, MS Plata 2007
Anterior vaginal repair for urinary incontinence in women CMA
Glazener, K Cooper 2001
Bladder neck needle suspension for urinary incontinence in
women Cathryn MA Glazener, Kevin Cooper 2004
JBI: Systematic Reviews
Haddow, G., Watts, R., Robertson, J. (2005). The effectiveness of a
pelvic floor muscle exercise program on urinary incontinence
following childbirth (Technical Report)
The Australian Centre for Rural and Remote Evidence Based Practice.
(Completed). Instruments for the Assessment of Faecal Incontinence
for Community-dwelling Older Persons. Toowoomba Health Service
District, Toowoomba, Queensland, Australia
A systematic review of psychometric evidence and expert opinion
regarding the assessment of faecal incontinence in older communitydwelling adults. The University of Queensland/Blue Care Research
and Practice Development Centre.
Hodgkinson, B. Hegney, D. Josephs, K. and Leira, E.A (Review in
progress). Systematic review of the effect of educational
interventions of urinary and faecal incontinence for health care
staff/carers/clients on level of knowledge, frequency of incontinence
episodes and hours spent on the management of incontinence
episodes. The University of Queensland/Blue Care Research and
Practice Development Centre.
Evidence-Based
Clinical Guidelines
Multi-Disciplinary, Allied Health, Nursing
New Zealand Continence Association Guidelines
http://www.continence.org.nz/guidelines.html
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Nocturia, Enuresis, Constipation
New Zealand Guidelines Group
http://www.nzgg.org.nz/index.cfm
Auckland District Health Board Jean Hay
Referral guidelines: Female Urinary Incontinence
NMAP: The UK’s gateway to high quality resources in
nursing, midwifery and allied health.
<http://www.nmap.ac.uk>
Royal College of Nursing (United Kingdom). Clinical
guidelines. http://www.rcn.org.uk/resources/guidelines.php
General & Medical
Guidelines International Network
http://www.g-i-n.net/
National Institute of Clinical Studies (NICS) (NHMRC)
http://www.nhmrc.gov.au/nics/asp/index.asp
Medical Journal of Australia Clinical Guidelines
http://www.mja.com.au/public/guides/guides.html
National Guideline Clearinghouse in the United
States of America found at http://www.guideline.gov/
Journals
International Journal of Evidence Based
Healthcare
The Journal of Evaluation in Clinical
Practice
Worldviews on Evidence-based Nursing
Bandolier
Evidence-Based Nursing
What information should
I be keeping up with?
Usefulness = Relevance X Validity
Work it takes to find out
J of Fam Pract 1994 38, 505-513
Relevance of Information
Is this research client/practice focused?
Will it change my practice / affect
clinical decision making?
Are these findings applicable to my
clients / practice?
Was the setting for this research similar
to my clients’ setting / practice setting?
Is the research valid?
Are the results significant?
What does experience and
expertise contribute?
Assessment skills
Judgment
Efficiency and effectiveness
More thoughtful, compassionate care
An ability to apply the appropriate
knowledge to the right situation
Knowledge that would contribute
to improving continence practice:
Effectiveness of continence treatments, therapy
and care
Experience of and responses to incontinence,
therapy, treatment, advertising, product use, etc.
Processes for providing continence care,
purchasing, etc.
Inequities in continence care provision / service
provision
Socio-cultural impacts of incontinence, buying
patterns, etc.
Issues generating conflicting perspectives
The Challenge for
Continence Care
Basic research to generate new knowledge
about continence treatment & care
Get continence issues on the EBP agenda
Undertake systematic reviews in relation to
core practices in continence care
Make this information accessible to
practitioners
Provide organisational support for EBP and
research
Fund research / access funding
Changes to Practice
Question practice decisions based on
authority alone
Reflect on practice
Look for evidence as a basis for decisionmaking
Use clinical guidelines based on evidence
that have been developed by others
Ongoing review of clinical guidelines,
based on evidence
Evaluate the outcomes of practice
Generate questions that need answering
Developing EBP Approaches
Develop and lobby for clinically-relevant
questions for systematic reviews
Learn how to apply the results of studies done by
others
Share knowledge / expertise with others eg.
attend conferences
Learn to read research articles and systematic
reviews critically eg. Start a journal club
Resources
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Use the library / databases
Develop a library of CATS (critically appraised topics)
Subscribe to the JBI, Cochrane
Develop research skills / team up with someone
who has research skills
Barriers to EBP
Attitudes
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Most clinicians do not read research literature,
use research findings (eg. Nagy, et al, 1992)
Resources
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Access to libraries, journals, systematic reviews,
research expertise, etc.
Support
Time, financial support to conduct research and
disseminate findings
 Organisational culture / structure
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Knowledge
Sources of Information
Different sources are required for different
types of evidence
Guidelines – professional organisations
 Systematic reviews - Evidence based
practice centres
 National or local data - grey literature,
organisational material
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Websites
Cochrane Collaboration
http://www.cochrane.org
Joanna Briggs Institute
http://www.joannabriggs.edu.au/about/home.php
NHS Centre for Reviews and Dissemination
The Database of Abstracts of Reviews of Effectiveness (DARE)
Campbell Collaboration
http://www.campbellcollaboration.org
The US Centre for Disease Control
http://www.cdc.gov/eval/resources.htm
National Institute for Clinical (NICS)
New Zealand Guideline Group
http://www.continence.org.nz/guidelines.html
JBI Resources
Systematic reviews
Best practice sheets
Evidence utilisation
Technical reports
COnNECT: Clinical Online Network of Evidence
for Care and Therapeutics
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Online facility providing resources and tools to search,
appraise, summarise, embed, utilise and evaluate
evidence-based information
PACES program: Practical Application of Clinical
Evidence System
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An on-line tool for health professionals to conduct an
audit in a large or small health care setting
The Future
Clinically-focused research
Clinicians developing and shaping their own
practice area through research, publication
Collaboration between clinicians and
academics to develop knowledge to support
evidence based practice eg. Research
positions in health agencies
More research into clinical practice
undertaken by/in collaboration with clinicians
Strategic planning for research activity in
clinical practice
Development of a library of evidence-based
knowledge
Clinically-focused, rigorous research
can be used to develop knowledge,
enhance practice, and validate the
value of practice in continence care.
The outcome of refining and applying
knowledge better care is for people with
incontinence
Thankyou
References
Sackett DC, Rosenberg WMC, Gray JAM,
Haynes RB & Richsrdson WS. (1996)
Evidence-based medicine: What it is and
What isn’t it. British Journal of Medicine, 312,
71-2.
Popay J, Rogers A, Williams G. (1998).
Rationale and standards for the systematic
review of qualitative literature in health
services research. Qual Health Res, 8(3),
341-351.
EBP - the next phase?
Effectiveness: RCT, cohort studies etc.
Appropriateness: meta-analysis / synthesis of
interpretive research
Feasibility: action research, critical
approaches
Basic research required to generate new
knowledge
Develop rigorous ways of evaluating the
findings from non-RCT research
Questions and Critique of
EBP in Continence Care
Don’t we do this now?
Could become a straight jacket for practice
Could be used as a cost cutting measure
What counts as evidence?
Focuses on the measurable, values
outcomes, not processes
Limited research evidence in continence care
Insufficient research skills
We have to implement practices right now
Where does experience and expertise fit?
NHMRC: Levels of Evidence 1995
I
Evidence obtained from a systematic review
of all relevant randomised controlled (RCT) trials
II
Evidence obtained from at least one properly
designed randomised controlled trial
III.1 Evidence obtained from well-designed
controlled trials without randomisation
III.2 Evidence obtained from well-designed cohort
or case-control analytic studies preferably
from more than one centre or research group
III.3 Evidence obtained from multiple time series
with or without the intervention. Dramatic
results in uncontrolled experiments
IV
Opinions of respected authorities, based on
clinical experience, descriptive studies, or
reports of expert committees
Key Questions
1. Evidence base
A
Several Level I or II studies with low risk of bias
B
one or two Level II studies with low risk of bias or SR/multiple Level III studies with low risk of bias
C
Level III studies with low risk of bias or Level I or II studies with moderate risk of bias
D
Level IV studies or Level I to III studies with high risk of bias
2. Consistency
A
All studies consistent
B
Most studies consistent and inconsistency can be explained
C
Some inconsistency, reflecting genuine uncertainty around question
D
Evidence is inconsistent
NA
Not applicable (one study only)
3. Clinical impact
A
Very large
B
Moderate
C
Slight
D
Restricted
4. Generalisability
A
Evidence directly generalisable to target population
B
Evidence directly generalisable to target population with some caveats
C
Evidence not directly generalisable to the target population but could be sensibly applied
D
Evidence not directly generalisable to target population and hard to judge whether it is sensible to apply
5. Applicability
A
Evidence directly applicable to Australian healthcare context
B
Evidence applicable to Australian healthcare context with few caveats
C
Evidence probably applicable to Australian healthcare context with some caveats
D
Evidence not applicable to Australian healthcare context