Chapter 3 Evidence-Based Clinical Practice: Distinguishing Best Practices

1. Chapter 3Evidence-Based Clinical Practice: Distinguishing Best Practices

2. 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 applicationsof evidence-based practice in patient care and clinical advancement.

3. 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.

4. 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.

5. 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.)

6. 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.

7. 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.

8. 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

9. Theory in Clinical Practice and Research • Theory in Clinical Practice: • 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.

10. 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

11. 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

12. “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.

13. “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.

14. “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.

15. “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).

16. 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.

17. “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).

18. 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.