In the above quote, Hodnett reminds us that what you find often depends on the question you ask. When searching for external treatment evidence, asking the right question is one of several important strategies you need to use to maximize your chances of finding the answer you seek. Chapter 3 explores both the foundations and implementation of constructing good questions about treatment. A common question asked is whether one treatment is better than another, which forms the basis of the PICO format described in Section 3.2. There are also many other questions that you can ask of the literature related to cost-effectiveness, appropriateness, user satisfaction. Petticrew and Roberts (2003) address many of these issues in Section 3.3. ASHA and other websites provide substantial resources covering the state-of-the-science for many speech-language interventions.
Relatively few of the questions that you ask in an external search will result in a definitive answer, and as suggested by David Levithan, some level of uncertainty will be part of every decision you make. This is where your critical evaluation and decision making skills come into play. You will notice that in the literature search example in section 3.4, my conclusions were based on a strategic search of ASHA’s evidence maps, partially supporting the positive impact of augmentative communication use on speech production. Finding mixed results for a given question may be fairly common in the speech-language field, due in part, to the lack of strong treatment effects associated with most interventions.
When the answers to our questions are mixed and/or complex, it becomes increasingly important to be aware of what is influencing your clinical decision making. As noted in the previous chapter, it is critical to recognize your motivations influencing the decisions you make and reflect on the examples of mistaken assumptions, unrecognized biases, and errors of thinking. It’s easy for self-centered ways of thinking to creep in and unconsciously influence your decisions. The evidence hierarchies, quality controls and critical questions introduced in this chapter are designed to help you evaluate external evidence sources for answers to your clinical questions.
Thought Questions and Exercises
You have been using auditory processing therapy techniques in your therapy practice for some years for children diagnosed with Central Auditory Processing Disorder (CAP). However, a recent review by a major insurer states that CAP-based therapies may be ineffective or not as appropriate as once thought (AETNA, 2011). This policy presents a serious dilemma to you and your colleagues since CAP-based therapies represent a significant portion of your clients and an important source of income for your agency. You have decided to review the current literature on CAP to determine what you will do next.
- Conduct an Evidence Review:
- Construct a PICO question and do a literature search using ASHA’s Practice Portal to examine the most current research findings of this issue.
- Carefully evaluate your evidence, comparing the points made by your search to the AETNA policy.
- Make a point-by-point comparison and evaluate the quality of evidence each brings to bear on the topics. Make sure that you assess the strength of each evidence source
- Figure out how you will deal with discrepant evidence (e.g., always rely on higher level evidence, factor in the relevance of the evidence source to your situation).
- Report your findings
- Report the results of your evidence search.
- Will you continue to provide CAP-based therapies to your clients? Explain your rationale.
- Describe your assumptions and upon which you based your decision?
Bibliography
Here are a few literature sources that provide comprehensive reviews of the external evidence search process.