Getting All the Pixels: How can we Increase the Evidence?

Abstract

The American Speech-Language-Hearing Association (ASHA) advocates that all Speech language pathologists must include the principles of evidence-based practice (EBP) in their clinical decisionmaking to ensure the provision of high quality interventions [1]. EBP is a trilateral construct consisting of external evidence, the clinical expertise of the clinician, and the needs of the client. Recently, consideration of the needs of the client, the so-called social evidence, has become increasingly important, especially in the discussion of quality [2]. However, when considering the three elements of EBP, the external evidence frequently receives the highest emphasis. In the context of communication disorders, randomized controlled trials (RCT), studies that are viewed as the best source of the highest level of evidence, are considered by many as the “gold standard” of treatment efficacy studies [3]. RCT studies are often difficult to conduct, as they are expensive and time-consuming. In the area of fluency disorders, there are few RCTs available, and we often have to rely on expert opinion rather than efficacy studies [4]. However, if such studies were the only evidence clinicians could rely on, it would be like having a high definition television and only receiving a limited number of pixels. Imagine the output, if all the red pixels were missing – the picture or evidence would be blurry! One option to increase the fidelity of the overall picture would be to take other evidence into account, for example a well-designed and well-reported case study. Such studies may not have the highest level of evidence, but could guide the speechlanguage pathologist when making clinical decisions. Smaller wellreported studies are not invalid and although they will not receive the highest rating of evidence they still can lead to well-informed clinical decision-making. But a far more important question is, could we widen the evidence base for these types of studies? How can the pixilation, the data sets that are available for these studies, be improved? Can the “gold standard” for lesser-investigated therapy methods be reached by increasing the data collected?