Meeting the Evidence-Based Standard

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Meeting the Evidence-Based Standard

• One Sky Center
• R. Dale Walker, MD, Director
• Michelle Singer, Communications Coordinator, ICMI
  Project Director
• Doug Bigelow, PhD, Deputy Director

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The Learning HealthCare System
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Outline

• Evidence-Based vs Culture-Based Dilemma
• What is Evidence?
• Multiple Streams of Evidence
• The Learning Healthcare System
• Description A Scientific Framework
• Some Culture-Based Interventions

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EBI CBI Dilemma

• Epistemological gulf
• Western
• Traditional AI/AN
• Epistemological debate
• Validity of traditional world view
• Freedom to live by a traditional world view
• Practical debate
• Controlling by purse strings

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Bridging EBI CBI

• Bridging
• Evidence is?
• Status of evidence for EBI
• How to meet reasonable standards of evidence
• Practice Improvement
• Multiple Streams of Evidence
• Learning Healthcare System

http//coce.samhsa.gov/cod_resources/PDF/OP5-Pract
ices-8-13-07.pdf
http//www.iom.edu/CMS/28312/RT-EBM/41894.aspx
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Sources of Evidence

• Intervention/program research
• Randomized Controlled Trials (RCT)
• Nonrandomized, uncontrolled
• Evaluation
• Adaptation of Proven Intervention
• Like a Proven Intervention
• Basis in Proven Theory, Principles, Facts

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Evidence-based InterventionsProcess and Criteria

• Criteria
• Fidelity
• Internal Validity (vs confounding variables)
• External validity
• Reliabilityrepeatability.
• Process
• Scientific experts
• Independent judging and rating
• Compilation and Summary

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Nature of Behavioral Intervention

• Therapeutic power of Choice
• Self-healing guided by expert healers
• Uniqueness of interpersonal relationships
• Complexity of factors

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Status of Evidence in EBI

1. Individual studies
2. Reviewed collections
3. Lists of model, best, promising, alternative
4. Survivors of meta-analyses

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The Buffalo jump for Ebi

• Meta-analysis
• Best Practice
• Review
• Research
• Description
• Practice
• Culture

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Reasonable standards of evidencefor improved
practices

• Best Practices highest scientific standards
• Balance point
• Reasonable standards are
• Repeatability
• Achievable within resources and constraints
• Allow conclusions without intolerable doubt
• Low risk of harm, if conclusions are wrong

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Adaptation-Adoption

• Adoption requires buy-in
• Acceptance
• Implementation

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Adaptation-Adoption

• Adaptation to unique local culture and context
• Players
• Rules, expectations, traditions
• Resources/collaborations
• Opportunity to contribute to strategic plan

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Adaptation-Adoption

• MI, CBT, SFP, Project Venture, Canoe Journey
  implementations
• are unique in every setting
• Every replication is an Adaptation

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EBI out of the box

• The EBI idea is changing
• SAMHSA multiple streams of evidence
• IOM Learning Healthcare System

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Other Sources of Evidence

• Intervention/program RTC Evaluation
• Adaptation of Proven Intervention
• Analogous to a Proven Intervention
• Basis in Proven Theory, Principles, Facts

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Description
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Importance of Program Manuals

• Operationalization a way of knowing/believing
• From black box to detail
• Consistency with body of knowledge
• Who, what, when, where, how, decisions
• Repeatability

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Proven Theory, Principles Facts

• Social ecology (influences)
• Prevention
• Universal/ selected/ indicated
• Risk and Resilience
• Readiness to Change
• Risk taking/seeking
• Stress vulnerability

• Modeling (observational learning)
• Instrumental learning
• Group dynamics
• Conformity, altruism
• Listening and support
• Catharsis
• Psychopharmacology

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Kinds of Intervention Strategy

• Screening
• Gatekeeping
• Diagnosis
• Treatment
• Traditional healing
• Traditional ritual/ceremony
• Postvention
• Parent/family training
• Group work

• School/institution-based
• Education/skills
• Experiential
• Socialization/acculturation
• Public Health (risk/resilience)
• Services develop/coord
• L E/justice/corrections
• Community competency
• Community change
• Culture

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AI/AN Prevention, Tx, Rehab Interventions

• Story telling
• Talking circles
• Sweat Lodge
• Ceremonies and Ritual
• Purification
• Passages
• Naming
• Grieving
• Drumming, singing, dancing

• Vision Quest
• Flute playing/meditation
• Reconciliation
• Mentoring
• Service learning
• GONA

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Best Practices

• Cultural Enhancement Through Story Telling
  (Tohono Oodham Res)
• AI Strengthening Families Program (U UT)
• Across Ages (Mentoring) (Temple U)
• Creating Lasting Family Connections
• Dare to Be You (Ute Res)
• With Eagles Wings (N. Arapaho Nat)
• Families That CareGuiding Good Choices

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Best Practices

• Families and Schools Together (Rural Wisconsin
  Res)
• Parenting Wisely
• Preparing for Drug Free Years
• Project Alert
• Project Venture (NIYLP)
• Promoting Alternative Thinking Strategies
• Zuni Life Skills (Zuni Pueblo)

http//www.spokane.wsu.edu/ResearchOutreach/wimhrt
/research2.asp
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Bottom Line

• Deal with Epistemological Gulf
• Know limitations of Evidence in EBI
• Agree upon Practice Improvement Goal
• Make credibility gains with Scientific
  Framework for Description
• Use existing practices and knowledge as evidence
  for similar CBI

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• Feel Free To Contact Us At
• One Sky Center
• (o) 503-494-3703
• onesky_at_ohsu.edu
• www.oneskycenter.org