Chapter 3 Evidence-Based Clinical Practice: Distinguishing Best Practices

Overview of Chapter The issues of evidence-based medicine reflect the question of how to apply clinical research literature: Why do disease and injury occur (epidemiology)? What can we do to prevent the condition in the patients in our offices (clinical epidemiology)? Diagnostics is an issue because without identification, the next piece (treatment) is meaningless. The other issue is cost containment. The role of evidence in defining and advancing clinical practice A guide through academic theory and research methods to practical applications of evidence-based practice in patient care and clinical advancement.

What is Evidence-Based Practice (EBP)? Evidence-based practice (EBP) refers to the process by which decisions about clinical practice are supported with research using scientific models and theoretical paradigms. Clinicians use the best, up-to-date clinical care research evidence to help diagnosis and to treat individual patients. Clinicians need be able to access, evaluate, interpret, and apply the medical literature.

Evidence-Based Practice (continued) EBP as a systematic inquiry process: (students/practitioners) Assess Ask Acquire Appraise Apply evidence to answer clinical problems Evidence-based clinical practice as a three-pronged approach to patient care: Valid research findings grounded in theory and science Clinical expertise and practical experience The medical needs, psycho-social interests, and ethical and religious values of the individual patient.

Hayward’s Evidence-Based Information Cycle Theoretical model that illustrates the process of practicing evidence-based medicine: (Adapted with permission from http://www.cche.net/info.asp. Framework developed by Dr. Robert Hayward, Director of Centre for Health Evidence. Accessed October 21, 2009.)

Hayward’s Evidence-Based Information Cycle (continued) Hayward’s Evidence-Based Information Cycle shows the cyclic nature of accessing the best information on the effectiveness of each intervention. Following this notion, EBP can be explained as an approach to medical practice in which clinicians endeavor to apply research evidence in decision- making processes underlying best practices in patient care.

Evidence–Based Practice… Is not an attempt to replace clinician judgment with scientific research. Is not a safeguard to confirm or manage practitioners’ clinical judgment. Is not a standardized treatment approach determined and dictated by science. Is not an agenda driven by administrators or policy makers to reduce medical expenses for more costly conditions by eliminating patient treatment options. Is not an authoritarian or repressive approach to clinical interventions and patient care. Does not denounce more traditional means of acquiring clinical knowledge.

The Role of Theory: Basic Definition Theory is based on general principles rather than specific instances. Theory can be explained as a set of facts, propositions, or principles analyzed in their relation to one another and used to explain phenomena. Theory connects and lends explanation. Theory emphasizes how concepts or ideas interrelate with one another

Theory in Clinical Practice and Research Theory is a conceptual framework for a set of ideas, principles, or guidelines that can provide a contextual outline for students and practitioners in the process of coming to a conclusion or determination about a clinical situation. Theory in Research: Theory represents a frame of reference, school of thought, or paradigm of science. A scientific theory (much more complex and dynamic then scientific law), refers to an entire group of related phenomena. A scientific law provides explanation for a specific single occurrence.

The Role of Research in EBP Research results can offer evidence that provides empirical support and validation for clinical decisions made in an attempt to provide optimal patient care. One role of research in EBP is to complement clinical experience with patient preference. Another role of research in EBP is to provide basic guidelines for conducting, interpreting, and applying empirical research to clinical practice

Finding, Evaluating, and Applying Evidence EBP is essentially about: Recognizing clinical problems Asking good clinical questions Finding, critically evaluating, analyzing, and synthesizing evidence Applying the most relevant evidence to clinical decisions and patient care recommendations

“How To” Steps for the EBP Process How to define a question or problem: assessment and ask The EBP process begins with a clinical question or a clinical problem. Clinical questions must be distinctive and clearly based on the nature of the clinical problem. Assessment involves identifying key issues and then asking good, answerable questions. Assessment yields information; informed questions yield informed answers. Good information generates more good information.

“How To” Steps for the EBP Process How to access research literature efficiently and gather evidence: acquire and appraise Find current, valid, high-quality evidence that provides information to help answer/solve your question/problem. The goal of your search is to collect all the available, relevant literature connected to patient interventions and the outcomes identified in your assessment. Remember: The stages of the scientific research process still apply to the steps of a systematic review.

“How To” Steps for the EBP Process How to analyze the strength of evidences: appraise Recognize the quality or level of evidence. Be aware that there are different strengths of evidence and that the hierarchy of strength of evidence is one component of the article appraisal process (see Chapter 7). Perform a systematic review to build a consensus as you synthesize the information gained from your evaluation of the literature. Ideally you would like to find: consistent results from one study to another; a low risk of bias; and general, clear-cut conclusions with an uncomplicated relevance to the clinical question.

“How To” Steps for the EBP Process How to conduct article appraisal: “Article appraisal” refers to the appraisal of evidence discussed relative to its quality (e.g., bias, power, generalizability of results).

How to Conduct Article Appraisal Critical Appraisal Skills Programme (CASP, 2006) provides suggestions for general guidelines for critical appraisal. 3 key questions: 1. Is the study valid? 2. What are the results? 3. Will the results help my patients? CASP suggests considering the following during article appraisal: Rigor—methodological rigor and addresses the appropriateness of the research methods in the study Credibility—credibility of the research findings and addresses the presentation and meaningfulness of the results Relevance—relevance of the study and addresses the usefulness and applicability of the results to the clinician and the patient.

“How To” Steps for the EBP Process How to understand basic research designs How to use the evidence to help yourself and your patients/population: apply Determine how to apply the knowledge obtained from the research evidence. Summarize the findings, and determine how or if the evidence connects to the clinical problem and provides a clear answer to the clinical issue in question. Establish conclusions directly supported by the evidence, and apply those findings to the question (minimize bias and reduce random error).

Chapter Summary and Key Points EBP is about recognizing clinical problems; asking good clinical questions; finding, critically evaluating, analyzing, and synthesizing the evidence; and applying the best, most relevant evidence to clinical decisions and patient care recommendations. The distinguishing characteristic of EBP is that it assigns a hierarchy to specific categories of evidence. The systematic review process is guided and directed based on the clinical question.