This document provides an introduction to evidence-based practice for optometry students. It defines evidence-based practice as combining the best available research evidence, patient preferences and circumstances, clinical expertise. The five steps of evidence-based practice are introduced: asking questions, acquiring evidence, appraising the evidence, applying to practice, and auditing outcomes. Sources of evidence are discussed, with randomized controlled trials positioned at the top of a pyramid of evidence hierarchy. The goals are to equip students with the skills and mindset of evidence-based practitioners.

1. LEC NUMBER 1 IN RESEARCH METHOS
STREAM:
INTRODUCTION TO EVIDENCE-BASED
PRACTICE.
Statistics lecture number 1: How to be an evidence-based
practitioner.
Given by: Dr Kirsten Challinor. k.challinor@unsw.edu.au
Acknowledgement for various content to: Dr Isabelle Jalbert, Dr
Catherine Suttle & Associate Prof Rob Jacobs
1

2. COMMONWEALTH OF AUSTRALIA
Copyright Regulations 1969
WARNING
This material has been reproduced and communicated to you by or on behalf of the
University of New South Wales pursuant to Part VB of the Copyright Act 1968 (the Act).
The material in this communication may be subject to copyright under the Act. Any further
reproduction or communication of this material by you may be the subject of copyright
protection under the Act.
Do not remove this notice.

3. WHAT IS EXPECTED OF YOU/
MY LEARNING PHILOSOPHY
 Think like a punk
 ‘A young person,
especially a member of a
rebellious counterculture group’
 Critical thinking.
 Question/ answer/ argue.
 Behave like a professional
 Part of becoming an expert at something is learning the
approach of an expert.
 You will not become an Optom or Vision Scientist the
day you graduate, you are becoming that now, slowly
over time. 3

4. AIMS/OUTLINE OF THIS LECTURE
 To introduce Evidence-based practice
 EBP is a state of mind. Not a one off lesson.
 You will be learning the steps of EBP throughout your
degree, across all courses.
 Definition and process of EBP.
4

5. DEFINITION OF EBP
5

6. Satterfield et al, 2009
THE EVOLUTION OF EBP
Further information on the history of EBP
https://www.eboptometry.com/content/optometry/article/brief-history-
evidence-based-practice-0
6

7. EVIDENCE BASED PRACTICE
EBP
(Hoffman, 2010)
7
EBP is the combination of the best available evidence from research, the patient’s
preferences/circumstances, the clinical environment and the practitioner’s expertise.

8. EBP IS NOT
8
(Dawes, 2005) http://www.biomedcentral.com/1472-6920/5/1
o Focused only on RCTs.
o “Cookbook” medicine.
o Interested only in cost
effectiveness.
o Intended to dictate
treatments to clinicians.

9. 9Suttle, C.M., Jalbert, I. & Alnahedh, T. Examining the evidence base used by
optometrists in Australia and New Zealand. Clinical & experimental optometry:
Journal of the Australian Optometrical Association 95, 28-36 (2012).
More than three-quarters rely heavily on information they gained at
undergraduate level (pink) or in continuing education (orange) as the
basis for clinical decisions.

10. PROJECT PURPOSE
The project aim was to
to ensure that Optometry & Vision
Science
graduates& professionalshave
theknowledgeandskillsrequiredfor
evidence-based practice (EBP).
http://www.eboptometry.com

11. WHY DO I WANT TO BE AN
EVIDENCE-BASED THINKER?
11

12. WHY DO I WANT TO BE AN EVIDENCE-BASED
THINKER?
 To pass your degree! The curriculum is becoming
EB. To achieve as a professional. The professional
competencies are changing.
 To provide the best care for your patient.
 Cost. Effectiveness.
 Skill for life. Understanding science reporting in
articles in the media. Helps you answer questions.
12

13. UNSW GRADUATES WILL BE:
Scholars who are:
 understanding of their discipline in its interdisciplinary context
 capable of independent and collaborative enquiry
 rigorous in their analysis, critique, and reflection
 able to apply their knowledge and skills to solving problems
 ethical practitioners
 capable of effective communication
 information literate
 digitally literate
Leaders who are:
 enterprising, innovative and creative
 capable of initiating as well as embracing change
 collaborative team workers
Professionals who are:
 capable of independent, self-directed practice
 capable of lifelong learning
 capable of operating within an agreed Code of Practice
Global Citizens who are:
 capable of applying their discipline in local, national and international contexts
 culturally aware and capable of respecting diversity and acting in socially just/responsible ways
 capable of environmental responsibility
https://my.unsw.edu.au/student/atoz/GraduateAttributes.html
13

14. OPTOM PROFESSIONAL COMPETENCIES
The broad goals and objectives of the program are described below. Graduate attributes are mapped for
each course within the program to the Optometrists Association Australia Universal (entry –level) and
Therapeutic Competency Standards for Optometry 2008 (ref Kiely P, ClinExpOptom 2009: 92: 362-386).
http://onlinelibrary.wiley.com/doi/10.1111/j.1444-0938.2009.00383.x/full
Upon completion of the Optometry program each graduate should be able to demonstrate the following;
 Understanding of vision science and the scientific basis to the practice of Optometry and the
acceptance of Optometry as a scientific discipline in its own right.
 Technical competence in the performance and recording of the tests and techniques available for the
practice of Optometry.
 The ability to integrate findings and to decide on further action regarding the subsequent
examination and management of the patient.
 The ability to communicate with the patient, show empathy and establish good rapport. By this means,
to ascertain history and symptoms and to communicate necessary information to the patient completely
and accurately.
 The ability to communicate accurately and intelligently with other health care professions and to function
effectively within the total health care system.
 An understanding of the wider implications of vision and visual deficiencies at home and work and the
acceptance of the patient as a whole person in an environment.
 An understanding of the legal aspects of the practice of Optometry.
 An understanding and acceptance of the ethical implications of dealing with patients, employers and
colleagues.
 An understanding of practice establishment, management and expansion concepts.
 An acceptance of the need for life long development and continuing education in Optometry and
a willingness to maintain and develop clinical skills, knowledge and expertise
 A commitment to the promotion of the profession of Optometry
 The ability to initiate and to contribute to research programs including those based in private
optometric practice.
 The ability to function as an independent and complete eye care practitioner, including care of those
with special needs and emergency care.
14

15. THE PROCESS OF LEARNING TO BE
AN EVIDENCE-BASED THINKER
Ask
Acquire
Appraise
Apply
Audit
15

16. FIVE STEPS IN EBP
Asking clinical questions
Translation of uncertainty to an answerable question
Acquiring information
Systematic retrieval of best evidence available
Appraising information
Critical appraisal of evidence for validity, clinical relevance, and
applicability
Applying information
Application of results in practice
Auditing practice
Evaluation of performance
Dawes et al, 2005
16

17. SOME OPTOMETRY RESEARCH QUESTIONS
 Can nutritional supplements prevent dry eye
symptoms in contact lens wear?
 Does flax seed oil improve ocular comfort in dry eye
patients?
 What complications arise post-LASIK surgery in
myopic Asians?
 Which contact lens solutions are most likely to
induce corneal staining?
17

18. ASK
The PICO strategy was developed to support this part
of the process by providing triggers for the
identification of terms, as follows:
 P: Person, Patient, Population or Problem
 I: Intervention
 C: Comparison
 O: Outcome.
“Does full-vs part-time occlusion in amblyopia (lazy
eye) treatment result in letter acuity improvement?”
18

19. P: Person, Patient, Population or Problem.
 type of patient & problem
I : Intervention.
 Intervention of interest.
19

20. C: Comparison
 This term applies when the clinical question will ask
about one intervention, or perhaps one diagnostic
strategy, versus another.
O: Outcome.
 measure or indicator
20

21. SOME OPTOMETRY EXAMPLES
 Can nutritional supplements prevent dry eye
symptoms in contact lens wear?
 Does flax seed oil improve ocular comfort in dry eye
patients?
 What complications arise post-LASIK surgery in
myopic Asians?
 Which contact lens solutions are most likely to
induce corneal staining?
21
How could these
questions be
improved?

22. ACQUIRE
 Searching for research evidence
 Filtering the available evidence
 Sources of research evidence to address clinical
questions
 The pyramid of evidence
22

23. 23

24. 24

25. SEARCHING FOR RESEARCH EVIDENCE
25
Keyword Synonym
P Flight passenger or traveller
and
I compression stockings or
and
C no compression stockings or
and
O deep vein thrombosis or DVT
Does wearing compression stockings (compared to not wearing them)
prevent DVT in passengers on long-haul flights?

26. FILTERING THE AVAILABLE EVIDENCE
 We must filter out the lower quality research
evidence and obtain full articles describing the best
quality available research evidence.
 To do this we consider:
 Currency – is the Abstract recent?
 Relevance – does the Abstract describe work that is
directly relevant to your question?
 Quality – is this evidence reliable?
 Tags and limiters. See homework tutorial for a list of
tags and limiters (you need to know this for your
assignment).
26

27. SOURCES OF EVIDENCE
 Primary research evidence is found in journal
articles publishing original research.
 Secondary research evidence is found in a range of
sources, including systematic reviews of
randomized controlled trials, such as Cochrane
reviews, which are valuable to busy practitioners
because they address particular clinical questions.
 See homework tutorial for a list of examples of
sources (you need to know this for your
assignment).
27

28. A VISUAL REPRESENTATION OF VARIOUS SOURCES
OF EVIDENCE: PYRAMID OF EVIDENCE
28
Go to this site and click on each of the triangle segments:
https://www.eboptometry.com/content/medical-optometry/step-2-
acquire/practitioners-students-teachers/step-2-acquire
Based on Haynes B (2006)

29. PYRAMID OF EVIDENCE
Based on Haynes B (2006)
Secondary sourcesPrimary sources

30. PYRAMID OF EVIDENCE
Based on Haynes B (2006)

31. Summaries: Evidence-
based clinical guidelines.

32. Summaries: Evidence-based clinical guidelines
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/di15.pdf
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp113_glaucoma_120404.pdf

33. AMERICAN OPTOMETRIC ASSOCIATION
WWW.AOA.ORG
American Academy of Ophthalmology
http://one.aao.org/CE/PracticeGuidelines/PPP.aspx

34. Synopses: Databases providing abstracts of research
relevant to clinic.

35. www.thecochranelibrary.com or through UNSW library databases, EBM reviews

36. PYRAMID OF EVIDENCE
Based on Haynes B (2006)
Secondary sourcePrimary sources

37. PYRAMID OF EVIDENCE
Source: UNSW Medicine online Tutorials

38. APPRAISE
Critical appraisal is the process of assessing and interpreting evidence
by systematically considering its validity and its relevance to the
question.
 Internal validity: the extent to which the research is reliable.
 External validity: is an indication of the generalisability of the
findings.

39. APPRAISE
“Real science is all about critically appraising the
evidence for somebody else’s position.” (Ben
Goldacre)
http://www.ted.com/talks/ben_goldacre_battling_bad_
science.html?quote=1094
39

40. APPRAISE
Critical appraisal is the process of assessing and
interpreting evidence by systematically considering its
validity and its relevance to the question.
 Internal validity: the extent to which the research is
reliable.
 External validity: is an indication of the
generalisability of the findings.
40

41. CRITICAL APPRASIAL
 http://www.eboptometry.com/content/optometry/step
-3-appraise/practitioners-students-teachers/step-3-
appraise
 Determining study design and level of evidence
 Critical appraisal of each paper - determining any
bias that would affect the results
41

42. APPRAISE
42
Questions Yes No
Were subjects randomized? The study is not likely to be biased by
subject grouping.
Subject allocation may cause bias.
Was there a control? Is the control group
within this study, or historical?
There is unlikely to be a placebo effect in
the treatment group. We can be less sure
of this, though, if the control group data
are taken from a previous study.
Subjects were in therapy, but there is no
comparison with those not in therapy, so
we cannot know to what extent any
treatment effect is due to the treatment.
Is the population clinically relevant for my
application?
Findings may be population-specific. The findings may apply to one population
but not to the population in which the
therapy is to be applied.
Is attrition (reduction in numbers)
described?
If attrition rate is low, the findings are not
confounded by this factor.
We do not know the results in subjects
who withdraw from the study.
Were experimenters and subjects “blind”
in this trial?
The findings are not biased by expectation
of outcomes.
The experimenters and the subjects may
have unintentionally or otherwise
affected the outcome.
Are the subject groups comparable? The subject groups were equal at
baseline, so are likely to have been
similarly affected.
Outcomes in the groups may differ due to
factors other than the treatment.
Was subject treatment equal across
groups, apart from the therapy?
The subject groups were equal in all
respects apart from the therapy.
Outcomes in the groups may differ due to
factors other than the treatment.
Are the results both clinically and
statistically significant?
The results are clinically relevant. Results may be statistically significant, but
have no clinical significance. They may not
be statistically significant, in which case
there is no effect.
http://www.eboptometry.com
EBP in action
Step 3: Appraise

43. GLOSSARY FOR CA WORKSHEET
Attrition: A gradual, natural reduction in membership or personnel.
Bias: a systematic as opposed to a random distortion of a statistic as a result of
sampling procedure.
Blinding/masking: the participants, investigators and/or assessors remain ignorant
concerning the treatments which participants are receiving. The aim is to minimise
observer bias, in which the assessor, the person making a measurement, have a prior
interest or belief that one treatment is better than another, and therefore scores one
better than another just because of that. In a single blind study it is may be the
participants who are are blind to their allocations, or those who are making
measurements of interest, the assessors. In a double blind study, at a minimum both
participants and assessors are blind to their allocations.
Clinical significance: the practical importance of a treatment effect - whether it has a
real genuine, palpable, noticeable effect on daily life
Control group: (in an experiment or clinical trial) a group of subjects closely
resembling the treatment group in many demographic variables but not receiving the
active medication or factor under study and thereby serving as a comparison group
when treatment results are evaluated.
Randomised/randomized: set up or distributed in a deliberately random way.
Placebo a) a substance having no pharmacological effect but given merely to satisfy a
patient who supposes it to be a medicine.
b) a substance having no pharmacological effect but administered as a control in
testing experimentally or clinically the efficacy of a biologically active preparation.
43

44. APPLY
 Combine research evidence with our own clinical
expertise to answer the question in the context of
the clinical environment and with consideration of
the patient’s preferences.
44

45. AUDIT
 Assess and adjust: evaluate your performance with
this patient / the population and the outcomes of
your intervention and adjust management
accordingly.
 In terms of the patient - practitioner relationship
concerning the management of a condition, this
would involve requesting the patient to return if
problems persist, or to actively make a follow-up
date for reviewal of the management planned.
 Analysis of clinical decisions (e.g. referral or
prescription) in types of patient cases, and this may
be retrospective via clinic records, or prospective.
45

46. IN SUMMARY-PROCESS OF EBP
ASK formulating
answerable
questions
ACQUIRE
searching for the
best evidence
APPRAISE
critically assess
the evidence
APPLY
the appraised evidence
to patient / practice
AUDIT
evaluating outcome of EBP
process
46
(Dawes, 2005)