Examining the relationship between evidence based practice and clinical effectiveness
A growing number of health care professionals are beginning to turn to evidence-based practices to achieve higher standards of patient care and service delivery. A recent series of telephone-administered surveys shows that nearly 68% of all therapists asked used an intervention method with a high or moderate evidence of effectiveness as per the Van Tulder’s rating system. Those physiotherapists that did use a method of intervention with a higher rating of evidence of efficiency had, on average, graduated within more recent years; and many these professionals had taken more post-graduate clinical courses (Mikhail, 2004).
Evidence-based practice is a growing trend within the health care profession. This trend can be partially attributed to the growing number of requests for proof that paid services will provide improvement (Ochsner, 2003). Clinical effectiveness requires that the treatment given will provide the best results in the fastest amount of time possible; evidence-based practice is a form of forced critical thinking that can bring about an improvement in clinical effectiveness. Evidence-based practice starts when medical practitioners address questions relating to clinical practices by using carefully controlled treatment studies—otherwise known as “clinical trials.” Treatment effectiveness research is then done to determine any benefits that might have come about by a particular approach while under the conditions specified during routine clinical practice.
By enforcing the use of evidence-based practice, two growing concerns within the medical community can be addressed: the overall quality of health care and cost control over treatments (Timmermans & Kolker, p.2). With the ultimate goal of furthering this approach to clinical care, many of today’s educators are beginning to recognize and develop these skills of evidence-based practice within their students. Evidence-based practice (EBP) can be best described as the “integration of best research evidence with clinical judgment and patient values” (Portney, p.1). This definition expresses the fundamental concepts surrounding evidence-based practice; these concepts also help influence how evidence-based practice needs to be integrated into the professional and educational programs.
The first step is to recognize evidence-based practice as an important component of decision making regarding the management of patient care. Secondly, there are several fundamental skills that are required in making efficient decisions for treatment, including the following: accessing, interpreting, and appraising literature as well as asking good clinical questions (Portney, p.1). However, finding and interpreting research literature is only one source of information to be used in making decisions; effective clinicians must also learn and exercise the skills needed to reasonably incorporate the information wisely while making their decisions.
After finding the needed information, practitioners need to interpret the information and examine the source. Not all sources are equal, and a large part of the necessary interpretation skills will need to be allocated to discerning the strong evidence against the weak evidence (Kully & Langevin, p.2). Several methods have been implemented to classify evidence-based on its overall strength; these lists are generally sorted to show the strongest evidence first followed by the weaker evidence. This hierarchy of evidence, with the analysis of randomized controlled trials (RTCs) at the center, has helped to promote the use of meta-analysis among policy makers and practitioners. There have been several debates over the need or usage of evidence research, including debates over the standards with which this evidence is evaluated (McGuire, p.4).
As the debate continues so does the public’s distrust in today’s medical profession; therefore so does the need for evidence-based practice grow. This form of critical thinking will force doctors within all fields to ask this question: “How do you know?” By answering this question, the over all costs and efficiency of clinical practice will go up with each new case.
With the amount of distrust, the growing risks of malpractice suits and the speed with which patients can gain information from sources such as the Internet, anybody who’s anybody within the health care profession of today’s world is learning or has learned the importance of evidence-based practice. Even when the practitioner is not obligated to find or sort the available evidence in reference to a particular case, even just claiming that a specific method of treatment is evidence-based will convey a high-level of credibility—something that is invaluable in today’s world of lawyers and high-levels of medical competition.
In some cases, the need for clinical effectiveness is crucial not just the overall cost of treating a patient, but whether or not that patient will later develop chronic symptoms. For example, many patients might not be able to recover from the earlier stages of back pain. Emotional and psychological distress coupled with misguided beliefs may interfere with a patient’s recovery—thereby raising the risk of developing a chronic disability (Hay et al, p.1). These and other observations have shown that psychosocial factors may interfere with the outcome of patients with low back pain.
Many of the same or similar factors that drove heightened interest in technology assessment and outcomes research are now driving the interest in evidence-based practices and critical decision making. These factors include: strong evidence that a large portion of the health care currently being provided is inadequate or inappropriate, large amounts of differences between the outcomes of treated patients that cannot be explained by demographics, and indications that many of today’s patients are not receiving beneficial care (Steinberg & Luce, p.1).
The term “evidence-based” itself is ubiquitous; requiring that this label be examined more closely—much like the label “low-carb.” Previous to the emergence of this form of forced critical thinking, bodies of evidence regarding medical treatments and RTCs were published in articles and health journals. Many of these articles were written by clinical experts of the time; however they lacked the necessary critical appraisal provided by study design methods. Evidence-based practice has been described as a “paradigm shift,” (Steinberg & Luce, p.2) but more accurate a description would be the next step in the evolutionary chain of focus on available evidence, having been in progress for years, and the critical evaluations of this evidence. Today, systematic reviews or meta-analyses of RTCs are considered to be among the highest level of evidence to be used as a guide for critical decision making:
A systematic review is a summary of evidence on a particular topic that uses a rigorous process for retrieving, critically appraising, and synthesizing studies in order to answer a question about a burning clinical question (Mazurak Melnyk, p.2).
Evidence-based clinical practice guidelines are based on rigorous reviews, such as systematic reviews and meta-analyses, of the strongest evidence within specific topics; this makes evidence-based guidelines the provider for the strongest levels of evidence when searching for clinical practice guidelines. RTCs also provide very strong evidence as they are able to specify that the results of a particular intervention were achieved by the application of that intervention without the influence of any external factors (Mazurak Melnyk, p.2).
Other than evidence clearinghouses, databases, and meta-analysis of research, a commonly used form of disseminating updated evidence is through the use of clinical practice guidelines. The United States Institute of Medicine has defined these clinical guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (Timmermans & Kolker, p.1)
Evidence-based practice remains under controversy because of the implications that using such guidelines leave many practitioners feeling as though their hands are tied—as though they were being told to do things a certain way rather than allowing them the freedom of making their own decisions regarding health care. However, the common goal is ultimately to raise the credibility of the health care profession by raising standards of care, effectiveness of expenditures, and overall patient satisfaction.
One challenge hindering the growth of evidence-based practice, if this growth can be hindered, is the perceived lack of a substantial amount of strong evidence (MacDermid, p.2). However, this challenge can easily be overcome by collaborating with researchers, and by asking thorough questions such as “what evidence is there and what evidence is needed?” (Del Bueno, p.3).
Besides knowing what evidence-based practice is and how to use this practice to think critically when making clinical decisions, a practitioner must also realize what evidence-based practice is not. Evidence-based practice is not an exact science, and this practice does not offer a blueprint on the exact methods of treatment to be used in various medical fields (Steves & Hootman, p.4). Other factors are necessary when making clinical decisions other than the evidence presented. These factors might include: sound judgment, personal experience and patient preferences.
Though evidence-based practice is still under much debate by practitioners, the effect that implementing this system of guidelines will have on today’s clinical effectiveness is apparent. Credibility within the medical professions can be restored as cost control is not reflective of the patient care given. Patients will begin to instill more trust to their health care providers. Adding the much needed critical thinking using the evidence as guidelines along with a few other factors can greatly boost, can lower cost not only to the offices of the practitioners but to the patients as well—with the added peace of mind that the patients are receiving adequate health care that fall under their demands for improvement through intervention. Evidence-based practice is needed on a much larger scale to ensure clinical effectiveness as the medical profession continues to evolve technologically and again as more illnesses and causes of these illnesses are discovered.
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