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Barbara Walker, Ph.D. Clinical Professor, Department of Psychology Professor, Department of Family Medicine University of Colorado, Denver Jeffrey L. Goodie, Ph.D., ABPP/ LCDR, USPHS Assistant Professor of Family Medicine Uniformed Services University of the Health Sciences Bethesda, MD Helen L. Coons, Ph.D., ABPP President and Clinical Director, Women’s Mental Health Associates Philadelphia, PA Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Drs. Walker, Coons and Goodie have not had any relevant financial relationships during the past 12 months. What is the scientific basis for this talk? In this symposium, we will define evidence-based practice (EBP), introduce participants to the associated skill-set, tools and new resources for doing EBP, and illustrate how it can be translated it into both primary and specialty collaborative care settings. Describe how evidence-based practice is used for clinical decision-making and the 5 steps associated with this process. Describe why it is necessary to adapt evidence-based methods for use in primary care. List examples of evidenced based assessment and intervention strategies to improve physical and psychosocial outcomes among women seen in collaborative ob/gyn and oncology practices. Describe how several interventions have been adapted to be effective in a primary care environment. What do you plan for this talk to change in the participant’s practice? Be familiar with and be better able to use evidence- based practice skills for clinical decision-making in collaborative care settings. Increased ability to apply gender-specific research to improve outcomes in collaborative ob/gyn and oncology settings. Increased use of evidence-based practice strategies that have been adapted for use in primary care, specifically with regard to insomnia, weight management, and PTSD. A learning assessment is required for CE credit. 1) List the 5 specific steps associated with clinical decision-making in evidence-based practice. 2) Name and explain how to access and search at least 2 databases that contain synthesized evidence-based research. 3) Give at least one example of how evidence based care can improve health and psychosocial outcomes. 4) Describe how evidence-based treatment has been adapted and found to be effective in primary care for treating insomnia, weight, and/or PTSD. Session # October __, 2011 0:00 AM 1) Fundamentals of Evidence-Based Practice: It’s more than applying evidence-based treatments (Barbara Walker) 2) Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD (Jeffrey Goodie) 3) Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes (Helen Coons) Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. EVIDENCE BASED MEDICINE Sackett et. al 1997 What should I do for this particular patient in front of me? Straus et. al, 2011 (4th ed.) Best available research evidence CD Patient’s values Clinical Expertise Best research available Clinical Expertise CD Patient characteristics, culture and preferences “The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (became policy of the American Psychological Association in August, 2005) OPERATIONALIZATION : 5 STEPS Best research available Patient characteristics, culture, preferences 1. ASK 2. ACQUIRE CD Clinical Expertise 3. APPRAISE 4. APPLY 5. ASSESS CD Evidence-based Practice TOP DOWN: What is the most effective intervention for this particular disorder? (ESTs, EB guidelines) BOTTOM UP: What should I do for this particular patient in front of me? (Clinical Decision Making) EBIDM: Eddy, D. Health Affairs, 24, no.1 (2005):9-17 By Content Therapy Diagnosis Harm Etiology Prognosis Cost-effectiveness By Format Background Foreground THIS SLIDE COURTESY OF SUE LONDON RUTH LILLY LIBRARY THIS SERIES COURTESY OF SUE LONDON IUPUI LIBRARY High Sensitivity High Specificity WHAT: Scientifically synthesized literature WHERE: Specialized databases HOW: Specialized search strategies/filters Evidence that has already been (scientifically) synthesized for us: Syntheses Summaries Systems Systems HOW? Start at the top Summaries (Clinical Evidence,Uptodate, Dynamed, ESTs, EB guidelines) Syntheses Systematic Reviews (COCHRANE) Individual Studies (Medline, Embase, PsycINFO, Cinahl • • • • • EBP has two sides: Top-down and Bottom up (a set of clinical decision-making resources and tools) Common language Setting / Context matters Need for primary and secondary literature studies in collaborative care Ultimate goal is to improve outcomes www.ebbp.org has training modules Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD Jeffrey L. Goodie, Ph.D., ABPP LCDR, USPHS Assistant Professor, Dept of Family Medicine Uniformed Services University Outline Three examples Weight Insomnia PTSD Medical or Behavioral health providers Outcomes Challenges Weight Goodie, J. L., Hunter, C., Hunter, C., McKnight, T., LeRoy, K., & Peterson, A. (2005, March). Comparison of weight loss interventions in a primary care setting: A pilot investigation. Paper presented at the 26th Annual Meeting of the Society of Behavioral Medicine, Boston, MA. Specialty Care Evidence Identification Setting realistic goals Self-monitoring Stimulus control Exercise to maintain weight loss "Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults.“ (1998). National Heart, Lung, and Blood Institute, NIH. Does primary care provider delivered evidence-based behavioral interventions for weight result in more weight loss? Procedures Enhanced Care Group Appointment 1 Set 10% weight loss goal for first 6 months Maintenance goal for second 6 months Discuss motivators and barriers Provided w/ calorie book Food diary for 12 days Appointment 2 (2 – 4 weeks later) Review food diary and C.A.M.E.S. Review barriers and motivators Procedures Enhanced Care Group, Cont’d Appointment 3 (2 – 4 weeks later) Discuss physical activity Provided w/ pedometer Set baseline and increase by 10% Appointment 4 – 5 Review progress. Again, discuss barriers and motivators Appointment 6 Set maintenance goals 1 year follow-up Procedures Minimal Contact Group Appointment 1 Discuss cutting calories and increased exercise No specific tools or training provided for PCP PCP could recommend any weight loss strategy Appointment 2 -5 Discuss Appointment 6 Plan any problems for 6 month maintenance 1 Year follow-up Results 60 40 20 0 -20 -40 N= 24 13 EC MC Insomnia Goodie, J. L., Isler, W., Hunter, C. L., & Peterson, A. L. (2009). Using behavioral health consultants to treat insomnia in primary care: a clinical case series. Journal of Clinical Psychology, 65, 294-304. Specialty Care Evidence Stimulus control Sleep restriction Sleep hygiene Relaxation Schutte-Rodin et al. (2008). J Clin Sleep Med. Morin et al., (1989). Sleep Research; Morin et al., (1994), American Journal of Psychiatry. Do CBT evidence-based treatments for insomnia decrease insomnia symptoms when delivered by a BHC in primary care? Methods Case Control Series (Goodie et al. 2009) 29 physician referred Primary Insomnia patients Limited exclusion criteria Intervention delivered by BHC Attend four appointments Assessment (30 mins) 1-2 intervention appointments (15-30 mins) Sleep hygiene, stimulus control, sleep restriction Relaxation Supplemental book Follow-up Outcomes Pre M (SD) Post M (SD) SII 26 (4) 15 (5) SOL (min) 49 (37) 24 (27) WASO (min) 41 (32) 13 (11) AVGWAK (min) 29 (36) 9 (7) EMA (min) 20 (16) 9 (10) TWT (min) 135 (50) 52 (38) TST (min) 366 (113) 404 (97) TIB (min) 499 (106) 459 (101) SE 72 (13) 88 (10) *Significant compared to α=.008; Goodie et al. (2009) F 107* 17* 19* 9* 12* 95* 4 5 84* η2 0.79 0.38 0.41 0.24 0.30 0.77 0.14 0.14 0.75 PTSD Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, A. Peterson, A. L., and the STRONG STAR Consortium. (2011). Treatment of activeduty military with PTSD in primary care: Early findings. Psychological Services 8(2), 104-113. Specialty Care Evidence PTSD Treatment Prolonged exposure Cognitive processing therapy Powers et al. (2010). Clinical Psychology Review 30(6): 635-641.; Cloitre, M. (2009). CNS Spectr 14(1 Suppl 1): 32-43. Do CBT evidence-based treatments for PTSD decrease PTSD symptoms when delivered by a BHC in primary care? Intervention Adapted forms of prolonged exposure and cognitive processing therapy Assessed and treated by BHC After initial assessment, 1 to 4 (up to 6) < 30 min appointments Weekly Homework between meetings Procedures Pt referred to BHC Appointment 0 Testing Appointment 1 Appointments 2-4 6 & 12 month Testing Appointment 0 Duration: thirty-minute appts Brief Assessment (PCL-M) Education Normal recovery curve; “getting stuck” Role of avoidance in maintaining symptoms Evidence for exposure-based treatments Presentation of treatment options Primary care vs Specialty care vs Self-care Appointment 1 “Confronting Uncomfortable Memories” workbook Write narrative of traumatic experience Answer cognitive/emotional processing questions Prescribe as homework Goal: 30 minutes write/review daily Self-monitor SUD’s Problem-solve homework implementation When/where of homework Barriers to completion Appointments Two to Four (optional 5, 6) Discuss homework completion Review SUD’s Read narrative out loud (at least once) Read answers to processing questions out loud Socratic dialogue on problematic beliefs Re-assign writing assignment as homework BHC has option of other CP questions Encourage opportunities for in vivo exposure % with PTSD Diagnosis (PSS-I) % meeting PTSD Dx 95 87.5 85 75 65 55 47.5 45 48.4 41.3 35 Baseline N=24 Post-tx 6-month N=17 N=16 1-year N=11 Overall Χ2=8.95, p=0.03; All time points different from baseline (p < .01) PCL-M Mean (SE) PCL-M Scores 60 55.3 (2.2) 55 50 45 42.4 (3.3) 41.7 (3.3) 40 39.3 (3.2) 35 Baseline N=24 Post-tx N=17 6-month N=17 1-year N=10 Overall F=6.51, p=0.002; All time points different from baseline (p < .003) Overall considerations What determines evidence-based care? What outcomes should we expect? Who can provide the evidence-based care? Challenges with research in primary care Questions Jeffrey L. Goodie, LCDR, USPHS Uniformed Services University (301) 295-9461 [email protected] Session # October __, 2011 0:00 AM Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes HELEN L. COONS, PH.D., ABPP PRESIDENT AND CLINICAL DIRECTOR WOMEN’S MENTAL HEALTH ASSOCIATES PHILADELPHIA, PA 19103 Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Faculty Disclosure I have not had any relevant financial relationships during the past 12 months. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? The presentation provides examples of evidenced based care in collaborative obstetrics and gynecology and oncology settings to improve physical and psychosocial outcomes. Research on depression in women; preparing them for diagnostic and treatment procedures; and the important benefits of exercise will be translated. Objectives 1) List research based interventions to assess and treat depression in women in collaborative ob/gyn and oncology settings. 2) Summarize evidenced based rational for preparing women for diagnostic and treatment procedures in collaborative ob/gyn and oncology settings. 3) Translate research on aerobic exercise to improve outcomes in collaborative ob/gyn and oncology settings. Expected Outcome What do you plan for this talk to change in the participant’s practice? 1) Increased focus on applying evidenced based interventions in collaborative primary care (i.e., ob/gyn) and oncology settings. 2) Increased application of gender specific research to improve outcomes in collaborative ob/gyn and oncology settings. Learning Assessment A learning assessment is required for CE credit. 1) Providing evidenced based care can improve health and psychosocial outcomes? 2) Actively preparing women for medical procedures in collaborative ob/gyn and oncology settings can improve health and psychological outcomes? 3) List the improved physical, psychological and cognitive outcomes associated with aerobic exercise in ob/gyn and oncology settings? Women’s Health and Mental Health Improving Outcomes Using EBP Collaborative/Integrated Health Care Settings Primary Care Settings (IOM) Internal and Family Medicine Pediatrics Geriatric Medicine Adolescent Medicine Obstetrics and Gynecology Specialty Care Settings Oncology Surgery Cardiology Neurology Endocrinology PMR Other Evidenced Based Care In Ob/Gyn and Oncology Settings Clinical Research Depression in Women Preparing for Dx and Tx Procedures Exercise Assessment Treatment Prevention Costs of Depression Patient and family Quality of life, loss of hope, resilience Functioning (days of disability, quality of work) Poor self-care Adherence to treatment recommendations Risk/Co-morbidity for other health conditions Obesity Cardiovascular disease Pain Medications Impact on children and other relationships Health Care System Health care system Increased Utilization Only 50% of adults with depression are getting treatment from a health professional Less than half (47%) of adults who get treatment receive minimally adequate care WHO Report (1996), JAMA (2003) Depression in Ob/Gyn Settings General Factors Specific Depression rates in Pregnancy Related women Trauma Caregiver issues Chronic stress Sleep deprivation Inadequate support SES Depression Anxiety Loss in any trimester Infertility Complications Gyn chronic conditions Pelvic ICS Vulvar diseases Women with Depression in Ob/Gyn Settings Inadequate care Not evidence based/informed Partial symptom reduction without full resolution of depression Failure to address underlying issues Misdiagnosis of medical disorder Medication complications Gender issues in etiology, assessment, treatment or prevention strategies Poor sleep quantity and quality Cognitive style Trauma history Failure to minimize risk for relapse or prevention patient future generations Active Application of Cognitive Treatment Reduce and then resolve depressive symptomatology and anxiety Markedly improve sleep Calmer, more intentional response to host of issues with less catastrophizing, over-personalization, etc. Earlier recognition when negative or ruminative cognitive style is present More aware of how cognitive style impacts children Specific strategies to reduce risk recurrent depression Improve over-all well-being for the long haul Evidenced Base Care in Oncology Breast Cancer One in 8 life time risk Second most common cause of cancer death after lung cancer Over 192,370 new cases dx annually in the USA 40,610 women die annually in USA Long term survival rate for early breast cancer has improved with new therapies – especially in younger women Prevalence rate is 2,533, 193 – survivors! Chronic disease model focused in enhancing quality of well-being and reducing impact of late effects of cancer and its treatment ACS 2010 FACTS AND FIGURES Depression in Women with Breast Cancer Women highly resilient Depression rates roughly 20% to 25% CBT Medications Tamoxifen metabolism and antidepressants • Jin et al (2005) J Natl Cancer Inst. Preparing Women for Diagnostic and Treatment Procedures in Collaborative Medical Settings Preparing women for initial and late issues Physical Cognitive Emotional Sexual Relationships Employment and professional Genetic risk across family Health and life insurance Preparing women for challenges across disease course Different trimesters Disease recurrence Advanced and end-stage disease Potentially Difficult Exams/Procedures in Ob/Gyn Settings Breast exam Gyn procedures Pelvic exam Pelvic ultrasound Colposcopy Endometrial biopsy HSG Hysteroscopy IVF procedures Dx. laps Cystoscopy/Urodyamics GI procedures Abdominal exam Rectal exam Endoscopy Colonoscopy Venipunctures Anesthesia Oral or dental exam Childbirth: Vaginal or C-section Any type of biopsy and surgery Hysterectomy Sterotatic core biopsy/needle loc Sentinel node biopsy Lumpectomy Mastectomy Reconstructive surgery Breast reduction Cancer surgery – colon/pelvic ext. Chemotherapy and Radiation MRI, Cat Scan, etc. Cardiac procedures Preparing Women for Breast Cancer Medical Procedures Diagnostic Mammograms MRI Ultrasound guided core biopsies Stereotactic core biopsies Needle localizations Dye Injection for Sentinel Node Biopsy Surgical Lumpectomy Mastectomy Reconstruction – several types Treatment Chemotherapy Radiation Hormonal Palliative Chemotherapy Shunt Nerve blocks Preventive Mastectomies TAB, LAVH with BSO Actively Use Evidenced Based Practice to Prepare Women for Procedures Provide accurate information about cancer and its treatments Assess patients/families fears and hopes Facilitate decision making about procedures Ask important questions, get second opinions Make decisions they will trust and not regret Mobilize informational, practical, social, and esteem support Help to pace the patient Decrease pain, bracing, and physiological reactivity Reduce anxiety and fatigue Increase feelings of self-efficacy, control and quality of life Encourage patients to be active participants in their recovery and healing o Impact time to recurrence and survival? o o o o o o o o o o o Benefits of Regular Exercise in Ob/Gyn and Oncology General Improves self esteem with sense of accomplishment Improve body image Improved cardiovascular fitness Reduce muscle discomfort Increase strength, flexibility, coordination Decreased risk for diabetes Weight control Weight bearing exercise to build bone and joint strength Reduced risks for falls Improve sleep Reduce hot flashes Reduce depression and anxiety Helps with cognitive functioning Improves sexual energy Improves intimate relationships Improved Quality of Life Improve immune function Improves post-surgical healing Ob/Gyn and Oncology Ob/gyn Sleep Perinatal anxiety and depression Improved pregnancy outcomes Post partum anxiety, depression, energy, wt management, body image Oncology Manage treatment side effects Increase energy, stamina Lymphedema symptoms Reduced risk of recurrence in ER+ breast cancers or general mortality EBC in Women’s Primary Care and Oncology Improve health outcomes Improve mental health outcomes Women’s well being! Feel free to contact us Barbara Walker [email protected] Jeffrey L. Goodie [email protected] Helen L. Coons [email protected] Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!