What is Evidence-Based Practice?

Welcome to Evidence Based Practice: Improving Practice, Improving Outcomes.

My name's Anne Dabrow Woods and I'm the Chief Nurse of Wolters Kluwer Health Medical Research Division, which consists of Lippincott Williams & Wilkins and Ovid Technologies.

And today I'm here to talk to you about evidence-based practice, what it is, what it isn't, why it makes a difference, and why it is so crucial to what's going on in healthcare today.

So what is the top global challenge that faces everyone, no matter where you are, if you're in the United States, if you're in Australia, if you're in Europe?

Everyone faces the same challenge in healthcare today, and that is to provide the evidence-based, cost-effective, quality care that will improve practice and improve patient outcomes.

That is the number one challenge faced by all healthcare providers and healthcare institutions today.

Why is this such an issue?

Only 20% of what we do as healthcare providers is based on evidence.

That means 80% of what we do is not based on evidence.

And only 55% of the time patients get the evidence-based recommendations to base their treatment.

That means the remainder of the time they are not getting the latest standard of care.

The other thing that's really important to consider here is it takes 15 to 20 years to get evidence into practice.

And that's simply way too long.

What this all means is our patients are not getting the care that they deserve.

So what is the solution?

The solution is to integrate evidence into practice to improve patient outcomes.

And the true overall solution is the Joanna Briggs Institute.

So let's talk about a little bit about the beginning of evidence-based practice.

Well, evidence-based practice really started back in the 1970s with Archie Cochrane, who was an epidemiologist out of the United Kingdom.

And he took a look at the way healthcare was being delivered in that country.

And what he realized is that patients were dying.

They were not getting the quality of care that they needed.

So he decided to look at a study where he took two groups, one

Evidence-based practice and evidence-based decision making is based on:

External evidence - systematic reviews, randomized control trials, best practice, and clinical practice guidelines that support a change in clinical practice.

Internal evidence - healthcare provider expertise, quality improvement projects, outcome management initiatives.

Patient.

Preferences - what does the patient really want when given several different options?

Patient values - quality of life.

The myth of evidence-based practice.

EBP resources do not make an EBP institution.

So why use evidence-based practice?

It leads to the highest quality care and patient outcomes.

It reduces healthcare costs.

It increases reimbursement and decreases denials.

It reduces geographic variations in the delivery of care.

It increases clinician empowerment and role satisfaction.

It reduces healthcare provider turnover rate.

It meets the expectations of an informed public.

Types of research: Quantitative.

Intervention and outcome research based on scientific methods.

Uses experimental controls and manipulation of variables.

Uses instruments to test and measure data.

Uses statistics to interpret data.

Examples.

Clinical trial - study is assigned by researcher.

Randomized controlled trial - assignment to an exposure is randomized.

Cohort study - observational study where people are followed forward in time to determine outcomes.

Case-control study - observational study with a control group that looks back in time (chart reviews).

Case report or case series - descriptive study without a comparison group.

Meta-analysis - analyzes several studies around the same or related hypothesis; often part of systematic reviews.

Clinical practice guidelines - identify and summarize the evidence related to prevention, diagnosis, prognosis, and treatment.

Types of research: Qualitative.

Used to understand human behavior.

Uses observations to assess group culture, beliefs, actions, and adaptation to life situations.

Data collection - direct observations, focus groups, key opinion leader interviews, contextual design.

Directional research - often done in with quantitative research or before it.

Examples.

Phenomenology - philosophy.

Focus on individual meaning, the "phenomenon".

Ethnography - anthropology.

Focuses on culture, social meaning.

Grounded Theory - social sciences.

Generates explanations, develops a theory.

Action Research - social sciences.

Researcher interacts with the participants to achieve change & empowers community to take back control and make change.

out of anthropology, so we look at groups of people who have a certain condition.

We know that qualitative research is very, very important to how we deliver care today, because you need to make sure that your patients are having a good experience with the care they're receiving.

Now, the highest level of research is considered secondary research, and this is the thing that we call a systematic review or meta-analysis.

And what is different about a systematic review and a meta-analysis is that it brings the same level of rigor to the review of all the research studies that have been done on a specific topic.

It brings the same level of rigor to the analysis of all those studies.

Here's another caveat.

Systematic reviews are very different than literature reviews.

Because systematic reviews and meta-analyses actually have to be peer-reviewed.

So that means two or more people have to be appraising all the studies that are included in a systematic review or a meta-analysis.

When you do a systematic review, you also need to look at a few other things.

To make sure that it's important to how we provide care to our patients.

You need to look at, is it really feasible, the results of the systematic review?

Can I really implement this with a specific patient population?

Is it going to be appropriate?

Is it meaningful to patient populations and to my practice as a healthcare provider?

And is it going to be effective?

Is it really going to make a difference?

We do know, though, that research evidence is not created equal.

So it's really important when healthcare providers take a look at the research that they get from a search, they need to determine what level of research they're looking at.

At the base, we have all the original research studies, and these are the things like the randomized control studies.

And and those type of things.

The next level up would be the systematic reviews and the meta-analyses.

Again, the systematic review and meta-analysis is done by a researcher looking at all the original research around a certain topic.

Doing a critical appraisal of it, a synthesis of it, and then putting it together as a systematic review.

So that's considered the higher level of of research, um, in the hierarchy of evidence.

But at the very top is our clinical decision support.

And clinical decision support are tools that healthcare providers can use, they read immediately, and they go put into practice immediately.

Now, why is this important?

Because healthcare providers at the bedside do not have time to read 100, 200, 300 page systematic reviews or meta-analysis and then go make a decision about a patient.

They have to read the evidence and put it into practice immediately.

And that's what clinical decision support tools do.

All clinical decision support tools should be based on systematic reviews, meta-analyses, evidence summaries, or the best available evidence.

The Joanna Briggs Institute goes one step further.

So they look at the levels of evidence, as we stated before, with the systematic reviews certainly being at the highest level.

But they also look at the other things I had mentioned before.

They look at the feasibility, the appropriateness, the meaningfulness, and the effectiveness of each recommendation to see if it will really make a difference in what we do in healthcare practice today.

But they add one more piece to that.

They look at the economic evidence.

Because let's face it, if an intervention is going to cost a healthcare system hundreds of thousands of dollars.

It is not going to be worthwhile for that system to put it in place because it's going to bankrupt the system.

So we need to make sure that the interventions that we are applying to our patients make good economic sense and they're also effective for our patients.

So what is evidence-based practice methodology?

What is it?

Well, there's many methodologies around evidence-based practice.

But when you look at all of them, they have some of the same attributes.

And the first one is they look at finding the evidence, generating the evidence, being able to search it.

And this is all done after you develop a good research question.

A burning question that a clinician needs to answer to change care for a patient.

The second piece is they need to appraise the evidence.

To see if it's good enough to put into practice.

Then they need to implement the evidence to have it make a difference.

And here's the key point.

They then have to go back and evaluate the practice changes to see if what they've done have really made a difference.

This is true evidence-based practice.

And unless a healthcare organization is doing all of these pieces, then they're really not truly an evidence-based practice institution.

The JBI methodology fits each of these pieces.

The first piece is healthcare evidence generation.

And this is where they actually take a look at all the research that is out there.

Their second piece is evidence synthesis.

And this is the same thing basically as evidence appraisal.

Their third piece is evidence knowledge transfer.

And that would be the evidence implementation piece.

They have evidence utilization where actually evidence is in use.

And then during the evidence utilization piece, they actually go back and they evaluate whether or not the practice changes that have been put into place have really made a difference for our patients and our practice.

Now, JBI is a group out of South Australia, in Adelaide, Australia.

But make no mistake, they are

Healthcare providers need the latest evidence.

To appraise it.

They need to implement it.

They need to evaluate whether or not what they've done has made a difference.

Researchers need to do all four parts of evidence-based practice.

They're the ones who are generating the evidence, appraising it, implementing it, and then evaluating whether or not the practice changes that the healthcare providers have made have made a difference.

Faculty, it's very, very important.

Today in academia, the concepts of evidence-based practice have to be integrated throughout all our educational systems as part of the curriculum.

So faculty need to teach the concepts of evidence-based practice.

And certainly everything that they're teaching about diseases, conditions, latest diagnostic studies, treatment recommendations has to be integrated throughout their curriculum.

And using a program like Joanna Briggs Institute will help them to be able to do that.

Students are very, very important.

We need to make sure we're teaching our students the latest evidence.

So they can go out and provide the very best care.

They're going to use it to learn about diseases and conditions.

The latest diagnostics.

Treatment recommendations.

They also need to know how to appraise the evidence.

Because when you look at the number of studies that are released every year related to healthcare interventions.

A student needs to know which ones they should use to change their practice.

So I hope you understand that evidence-based practice is not just about providing the evidence and then calling yourself an evidence-based practice institution.

It's really about taking the evidence, appraising it, implementing it into practice, and then evaluating whether or not what you've done has made a difference.

That is true evidence-based practice.

Thank you very much.