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An Introduction to Evidence-based Practice in Wound Care

An Introduction to Evidence-based Practice in Wound Care

An Introduction to Evidence-based Practice in Wound Care

INTRODUCTION

Overview

A core competency for all healthcare providers is evidence-based practice (EBP).[1] Failure to consider the quality of evidence can lead to misguided recommendations by clinical guidelines or to misinterpretations of guidelines by clinicians that may result in harm to their patients.[2] Literacy in interpreting the quality of evidence helps prevent these errors.[2]

This topic provides an introduction to evidence-based practice and research in wound care. 

Background

Definitions

  • Evidence-based practice: this term refers to the act of making clinical decisions based on the best available evidence, that is, resulting from practitioners reviewing information from powerful data, instead of relying on single observations or traditions.[3] Evidence-based practice is the integration of clinical expertise with the best available clinical evidence from systematic research and with patient preferences/values in approaching any clinical case.[3]
    • Key components of the evidence-based approach include the development of important clinical questions and critical assessment of the type and level of evidence available.[3] The level of evidence is derived from the available clinical studies that aim to answer a specific clinical question.


TYPES OF CLINICAL STUDIES 

Table 1 lists different types of clinical studies and their descriptions.

Table 1. Different types of clinical studies according to NICE/UK [3][4]

Type of clinical studyDescription
Meta-analysisA statistical technique for combining (pooling) the results of a number of studies that address the same question and report on the same outcomes to produce a summary result. The aim is to derive more precise and clear information from a large data pool. It is generally more likely to reliably confirm or refute a hypothesis than the individual trials
Randomized controlled trial (RCT)
A comparative study in which participants are randomly allocated to intervention and control groups and followed up to examine differences in outcomes between the groups 
Cohort study
A retrospective or prospective follow-up study. People to be followed up are grouped on the basis of whether or not they have been exposed to a suspected risk factor or intervention. A cohort study can be comparative, in which case two or more groups are selected on the basis of differences in their exposure to the intervention of interest. 
Prospective cohort study
An observational study that takes a group (cohort) of patients and follows their progress over time in order to measure outcomes such as disease or mortality rates and make comparisons according to the treatments or interventions that patients received. Prospective cohorts are assembled in the present and followed into the future 
Cross-sectional study
The observation of a defined set of people at a single point in time or time period. This type of study contrasts with a longitudinal study, which follows a set of people over a period of time 
Observational study 
Retrospective or prospective study in which the investigator observes the natural course of events with or without control groups (for example, cohort studies and case-control studies) 
Case-control study 
Comparative observational study in which the investigator selects people who have experienced an event (for example, developed a disease) and others who have not (controls), and then collects data to determine previous exposure to a possible cause
Case series 
Report of a number of cases of a given disease, usually covering the course of the disease and the response to treatment. There is no comparison (control) group of patients 
Case report 
Report of one or two of cases of a given disease, usually covering the course of the disease and the response to treatment. There is no comparison (control) group of patients

LEVELS OF EVIDENCE

 A cornerstone of evidence-based practice is the hierarchical system of classifying evidence. Different types of evidence are available and their relative importance for changing clinical  practice has been organized into a hierarchy.[3]

The levels of evidence were originally described in a report by the Canadian Task Force in 1979 (Table 2).[5] Since the introduction of levels of evidence, many other organizations have developed a variation of the original classification system. [6] As a result, clinical practice guidelines have been inconsistent in how they rate the quality of evidence and the strength of recommendations.[2]

Table 2. Canadian Task Force on the Periodic Health Examination’s Levels of Evidence [5][6]

LevelType of evidence
IAt least 1 RCT with proper randomization
II.1Well designed cohort or case-control study
II.2Time series comparisons or dramatic results from uncontrolled studies
IIIExpert opinions

GRADE APPROACH

The Grading of Recommendations Assessment, Development and Evaluation (short GRADE) is a systematic approach to rating the certainty of evidence in systematic reviews and other evidence syntheses. [7] The GRADE working group began in the year 2000 as an informal collaboration of people with an interest in addressing the shortcomings of grading systems in health care. The working group has developed a common, sensible and transparent approach to grading quality (or certainty) of evidence and strength of recommendations. Many international organizations have provided input into the development of the GRADE approach which is now considered the standard in guideline development, utilized by over 100 organizations worldwide [7], including WoundReference.

What makes a good grading system?

Several grading systems have been used by guideline authors. However, not all grading systems separate decisions regarding the quality of evidence from strength of recommendations.[2] This may result in confusion, as high quality evidence does not necessarily imply strong recommendations, and low quality evidence can lead to strong recommendations. Grading systems that are simple with respect to judgments both about the quality of the evidence and the strength of recommendations facilitate use by patients, clinicians, and policy makers.[2]

How does the GRADE system classify quality of evidence?

The GRADE system classifies quality of evidence in one of four levels: high, moderate, low, and very low (Table 3).[2]

Table 3. GRADE certainty ratings  [8]

CertaintyDescription
High

The authors have a lot of confidence that the true effect is similar to the estimated effect

ModerateThe authors believe that the true effect is probably close to the estimated effect
LowThe true effect might be markedly different from the estimated effect
Very lowThe true effect is probably markedly different from the estimated effect

  • Evidence based on RCTs begins as high quality evidence, but confidence in the evidence may be decreased for several reasons, including [2]:
    • Study limitations
    • Inconsistency of results
    • Indirectness of evidence
    • Imprecision
    • Reporting bias
  • Although observational studies (e.g. cohort and case-control studies) start with a “low certainty” rating, grading upwards may be warranted if the magnitude of the treatment effect is very large, if there is evidence of a dose-response relation or if all plausible biases would decrease the magnitude of an apparent treatment effect.[2]

For more information on the GRADE approach, please refer to resources on Grade Working Group, Cochrane.org and BMJ Best Practice.

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Jimenez YA, Punch A, Lewis SJ, Reed W et al. Teaching evidence-based practice: Case study of an integrated assessment task for diagnostic radiography students. Journal of medical imaging and radiation sciences. 2022;volume 53(3):341-346.
  2. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group. et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ (Clinical research ed.). 2008;volume 336(7650):924-6.
  3. Gottrup F, Apelqvist J, Price P, European Wound Management Association Patient Outcome Group. et al. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. Journal of wound care. 2010;volume 19(6):237-68.
  4. NICE UK. Developing NICE guidelines: the manual . 2014;.
  5. . The periodic health examination. Canadian Task Force on the Periodic Health Examination. Canadian Medical Association journal. 1979;volume 121(9):1193-254.
  6. Burns PB, Rohrich RJ, Chung KC et al. The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery. 2011;volume 128(1):305-310.
  7. Siemieniuk R, Guyatt G et al. What is GRADE? .;.
  8. GRADE. Grade Working Group .;.
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