Evidence-Based Practice

Jeremy Steglitz, Jennifer L Warnick, Sara A Hoffman, Winter Johnston, and Bonnie Spring, Northwestern University,
Chicago, IL, USA
Ó 2015 Elsevier Ltd. All rights reserved.

Abstract

Evidence-based practice (EBP) is an approach that aims to improve the process through which high-quality scientific research
evidence can be obtained and translated into the best practical decisions to improve health. The interprofessional model of
EBP emphasizes shared decision-making within the context of the most important advances of the various health professions.
The model depicts three data streams that are integrated in the decision-making process: evidence, resources, and patient
characteristics. Health professionals can play several different roles in the EBP process, including primary researchers,
systematic reviewers, and clinicians. Carrying out the EBP process involves five steps, including Ask, Acquire, Appraise, Apply,
and Analyze and Adjust. A new generation of research designs, such as the Sequential Multiphased Adaptive Randomized
Trial, has been put forward to develop treatment algorithms that optimally capture the Apply, Analyze and Adjust steps of the
EBP process.

Definition not based on science, and a motivation that promoted profit

rather than public service (Flexner, 1910). The Flexner Report
Evidence-based practice (EBP) is an approach that aims to established an educational quality standard that many of the
improve the process through which high-quality scientific existing medical schools could not meet. Therefore, more
research evidence can be obtained and translated into the than half of all medical schools closed by 1935 (Beck, 2004).
best practical decisions to improve health. Research findings This report is widely regarded as the start of the EBM
derived from the systematic collection of data through observa- movement.
tion and experiment, as well as the formulation of questions A second main catalyst for the EBM movement came from
and testing of hypotheses comprise the evidence supporting Archibald Cochrane, a British epidemiologist who aimed to
practice. EBP harmonizes the standards used to conduct, report, establish a rational, systematic basis for determining what treat-
evaluate, and distribute research results so as to increase their ments should be covered by health care (Cochrane, 1972).
application to practice and policy. EBP also involves the use Cochrane argued that because resources for health care are inev-
of conscientious and explicit decision-making that integrates itably limited, it is essential that scarce dollars be allocated only
consideration of the best available research evidence, client for procedures of demonstrated worth. He argued that random-
characteristics (including preferences), and resources. Best ized controlled trials (RCTs) offer the most unbiased, reliable
available research is defined as contextually relevant and best method to evaluate the effectiveness of treatments, warranting
in quality, according to consensually accepted scientific stan- their placement at the top of a hierarchy of evidence. Accord-
dards for different types of questions. Practical decisions rele- ingly, findings from high-quality RCTs are given greater credence
vant to EBP often involve the selection of an assessment or than those from observational studies, case studies, and expert
intervention. While professionals practicing evidence-based opinion when determining whether a treatment is effective.
medicine (EBM) often need to choose among treatments Followers of Cochrane’s work subsequently established the
involving drugs or devices, those practicing evidence-based Cochrane Collaboration (www.cochrane.org), a worldwide
behavioral medicine (EBBM) usually make selections among network that tracks, critically appraises, and synthesizes results
nondrug and nondevice behavioral or psychosocial of RCTs, publishing their findings online.
interventions. In the 1990s, a group of clinical epidemiologists working at
Canada’s McMaster University under the direction of David
Sackett and Gordon Guyatt spearheaded the third initiative
History of EBP that catalyzed the EBM movement. This group’s mission was
to close the research-to-practice gap by encouraging physicians
The origins of EBP are usually dated to 1910, when the to engage in lifelong learning about new research findings
American Medical Association and the Carnegie Foundation (Sackett and Rosenberg, 1995a,b). The McMaster group was
commissioned Abraham Flexner, a research scholar at the motivated by evidence that health professionals primarily
Carnegie Foundation for the Advancement of Teaching, to implement treatment practices learned during training
survey American and Canadian medical schools. The Flexner but neglect new and often more efficacious treatments that
Report, as it was called, represented a major effort to reform emerged subsequently (Isaacs and Fitzgerald, 1999). To change
medical education by placing it on a scientific foundation. Flex- this habit, the McMaster group developed methods for health
ner surveyed 155 medical schools and severely criticized the professionals to find, assess, and apply research results.
training offered by many of them. His findings revealed that However, the group encountered resistance from health profes-
most medical schools offered lax clinical training, a curriculum sionals who believed that exclusive practice based upon

332 International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 8 http://dx.doi.org/10.1016/B978-0-08-097086-8.10540-9
 Evidence-Based Practice 333

research findings devalued clinical expertise and experience work, public health, and information sciences (www.ebbp.
(Haynes et al., 1996). To overcome this perceived slight against org). The Council’s first task was to formulate a conceptual
practicing clinicians, Guyatt et al. (1992) renamed the model that could accommodate the diverse historic traditions
approach ‘evidence-based medicine’ in place of ‘scientific medi- as well as the individual- and population-level behavioral
cine.’ In this newest model, EBM was presented as an approach interventions that different health professions implement.
that tied together and utilized research, patient characteristics, Initially, the conceptual model for EBM emphasized only
and expertise to formulate best treatment practice, as opposed a single parameter: research (Sackett et al., 1996). Later, the
to relying solely on research findings (Haynes et al., 1996; EBM model expanded to include other considerations such as
Sackett et al., 1996). clinical experience and specific patient needs. The EBM defini-
tion stated that: “evidence-based medicine requires the integra-
tion of the best research evidence with clinical expertise and the
EBM to EBBM patient’s unique values and circumstances” (Strauss et al.,
2005). EBBM expanded upon EBM by adding nondrug, nonde-
To evaluate interventions besides drugs or devices, health profes- vice treatments. EBBP went one step further by consolidating
sionals in the behavioral sciences also needed a standard to eval- across different disciplinary frameworks for EBP. The goal
uate behavioral treatments. The first entity to take on this task of was to develop a conceptual model that could be shared by
conceptualizing EBBM was the Society of Behavioral Medicine’s a more diverse interprofessional health-care team, whose
EBBM Committee. Established in 2000 with support from the members all require core competency in EBP (Greiner and
National Institutes of Health (NIH) Office of Behavioral and Knebel, 2003). This shared EBP model supports jointly held
Social Science Research (OBSSR) under Acting Director, Peter vocabulary, foundational assumptions, and practice principles
Kaufmann, the first EBBM Committee, first chaired by Karina that unite the team of professionals in medicine, nursing,
Davidson, defined its scope to include behavioral interventions psychology, social work, public policy, and information
that prevent disease, promote health and adherence to treat- sciences. A unified EBP eliminates the need to have separate
ment, or change biological determinants of behavioral condi- models for different disciplines (Satterfield et al., 2009;
tions (Davidson et al., 2003). Initially, this committee Spring and Hitchcock, 2009).
familiarized behavioral medicine researchers with the Consoli-
dated Standards of Reporting Trials (CONSORT) guidelines
that encourage comprehensive, transparent reporting of RCTs Interprofessional Model of EBP
in medical journals (Schulz et al., 2010). This effort was one
of many that led behavioral science journals to adopt the The interprofessional model of EBP (Figure 1) emphasizes
CONSORT guidelines for publishing clinical trials. Among the shared decision-making within the context of the most important
first behavioral science journals to adopt CONSORT were Annals advances of the various health professions, including those
of Behavioral Medicine, Health Psychology, International Journal of mentioned above. The model depicts three data streams
Behavioral Medicine, and the Journal of Consulting and Clinical that are integrated in the decision-making process: evidence,
Psychology. The EBBM committee also addressed other weak- resources, and patient characteristics. The interprofessional EBP
nesses in the quality of behavioral clinical trials, especially model is grounded in an ecological framework that emphasizes
with regard to the analytic approach. Numerous behavioral treat- the importance of considering environmental and organizational
ment trials were found to have analyzed data only from those spheres when conceptualizing the problem and designing
who completed the final assessment in a clinical trial or who a course of treatment.
experienced a full dose of treatment (Pagoto et al., 2009;
Spring et al., 2007). Since then, use of the intent-to-treat policy
has increasingly become normative in behavioral science, such
Best Research Evidence
that data from all randomized participants are included in study
Evidence refers to research findings from the systematic collec-
analyses according to the condition to which they were assigned.
tion of data through observation and experiment grounded in

EBBM Evolves to EBBP, and Then to EBP

Best available
By 2006, the US health-care crisis was in full swing. With it research
came the need for a better, more integrated system of care evidence Environment and
organizational
that addressed mental as well as physical health for the sick context
and prevention for the well. The only way to accomplish all Decision-making
of this was by the coordinated efforts of an interprofessional
team. It became clear that the EBBM approach needed to be Client/population
characteristics, Resources,
upgraded to include all health professionals. Thus, OBSSR state, needs, including
values, and practitioner
sponsored the Council on Evidence-Based Behavioral Practice preferences expertise
(EBBP), chaired by Bonnie Spring, and its scientific and clini-
cian advisory boards. The composition of the Council and
the Boards was determinedly interprofessional, combining
representatives from medicine, nursing, psychology, social Figure 1 Interprofessional model of EBP.
334 Evidence-Based Practice

the formulation of questions and hypothesis testing. That, 3. Communication and collaboration skills involve the capacity
which is deemed best research evidence is contingent on the to convey information clearly and appropriately. Further,
particular question that needs to be addressed (Sackett and they include the ability to listen, observe, adjust, and
Wennberg, 1997). A question concerning etiology or prog- negotiate in order to achieve an agreed-upon treatment
nosis, for example, is optimally answered through a longitu- plan.
dinal cohort research study design. On the other hand, 4. Engagement and intervention skills entail proficiency at moti-
a question about efficacy and effectiveness of treatments bene- vating interest, constructive involvement, and positive
fits from an RCT that is less susceptible to bias and error. change from individuals, groups, organizations, commu-
Treatment-based questions can be addressed particularly well nities, and other entities affected by health decisions.
with the systematic review, which synthesizes the findings
A recent development in EBP is resource-sensitive practice
from multiple RCTs (Oxford Center for Evidence-Based Medi-
guidelines that review evidence for appropriate practice recom-
cine, 2001). Recent interest in personalized care has generated
mendations given an available level of resources (cf Fried
interest in contextualized research evidence that is uniquely
and Krabshuis, 2008). Resource-sensitive guidelines enable
applicable to a particular patient and practice context
decision-makers to appraise the level of intervention intensity
(Weaver et al., 2005; Westfall et al., 2007). This has led to
that optimizes the available degree of accessible infrastructure,
a resurgence of interest in the single-case experimental design
human capital, and financial resources.
(Dallery et al., 2013), which some representations of the
evidence hierarchy place at the top of the evidence pyramid
(Figure 2). Patient Characteristics
Patient characteristics are a key set of contextualizing factors.
Resources They include individual attributes such as state and trait varia-
tion in condition, needs, history of treatment response, values,
Resources refer to the skills and infrastructure that are required and preferences that all influence whether a treatment is well
to provide EBPs. Resources needed to deliver treatments include matched to a particular patient. When deciding whether avail-
physical, technological, financial, and personnel assets (e.g., able research evidence is relevant to a given individual, health
office space, technological support, insurance reimbursement, professionals need to assess the comparability between patient
and expert health professionals trained in an evidence-based and study population. Tailoring surface aspects of the treat-
treatment). Additional resources may include institutional ment can enhance its acceptability to the patient, so long as
endorsement by higher administration and agreement from modifications do not stray so far from fidelity to core treatment
other system components to make a treatment available. elements that treatment loses its effectiveness (National Cancer
The interprofessional EBP model breaks down clinician Institute, 2006).
expertise into four categories of skill: assessment skills, EBP Patient preferences are a singular type of contextualizing
process skills, communication and collaboration skills, and variable. Although patient preferences are a particularly vital
engagement and intervention skills. part of shared decision-making, they are the least developed
1. Assessment skills refer to the appraisal of patient characteris- aspect of the EBP model. Shared decision-making is grounded
tics, problems, values and expectations, and environmental in the empowering of patients to self-manage their health and
factors. health care. Two preconditions for shared decision-making
2. EBP process skills are defined by competency in carrying out exist. The first is departure from a paternalistic model of care
the steps of the EBP process: ask well-formulated questions, in which the clinician makes decisions on the patient’s behalf.
acquire best available research evidence, appraise quality The second is adoption of a culturally informed model of
and relevance of evidence, apply evidence, analyze change, care, whereby health professionals assist patients in clarifying
and adjust treatment accordingly. their own values and treatment preferences.

Health Professionals’ Roles in EBP

Meta- Health professionals can play several different roles in the EBP
analysis process (Figure 3).
Systematic First, they can be primary researchers who directly
reviews contribute to forming the evidence base. Primary researchers
Randomized not only develop new treatments, but also design, conduct,
controlled trials
analyze, and report research that evaluates the efficacy and
Cohort studies effectiveness of interventions. Ideally, they will conduct RCTs
to evaluate whether a treatment works. If, however, time and
Case control studies resources are insufficient to conduct an RCT, primary
researchers may use alternative designs such as an intermittent
Case reports time series.
A second role that health professionals can play is that of
Animal research systematic reviewers, whereby they act as evidence synthesizers.
They aggregate primary research to analyze and interpret
Figure 2 Evidence hierarchy. synthesized findings that can be accessed and used efficiently
 Evidence-Based Practice 335

from each of the three EBP circles. Unlike the primary

Primary Systematic researcher or systematic reviewer, the clinician interacts
researcher reviewer directly with the two circles of the EBP model that concern
patient characteristics and resource considerations. Addition-
ally, health professionals are research consumers in that they
access research evidence and assess its quality and relevance
for the patient and context at hand. Secondary, synthesized,
Best available critically preappraised evidence sources, such as systematic
research reviews or EBP guidelines on www.guidelines.gov are inten-
evidence Environment and tionally designed to give the busy health professional a way
organizational
context to efficiently find the best research-tested answer to the most
Decision-making commonly asked practice questions. In some circumstances,
however, available systematic reviews and treatment guide-
Client/population Resources, lines may not provide an answer, requiring the clinician to
characteristics,
state, needs, including search the primary literature to identify relevant research. To
values, and practitioner
preferences expertise
enhance the simplicity of the clinician’s complex job, the
five-step EBP process delineates a recommended series of steps
that health professionals can follow to address each of the
three circles of the EBP model.

The Five Steps of EBP

Practitioner
Carrying out the EBP process involves five steps (Figure 4):
Step 1: Ask patient-oriented, well-formulated questions about
the health status and contexts of individuals, communities,
Figure 3 Roles of health professionals in the EBP model.
or populations.
Step 2: Acquire the best available evidence to answer the
questions.
by health professionals. The role of the systematic reviewer is
Step 3: Appraise the evidence critically for validity and appli-
particularly critical within the EBP framework due both to
cability to the problem at hand.
the rapid proliferation of the scientific literature and health
Step 4: Apply the evidence by engaging in collaborative health
professionals’ limited time to remain comprehensively
decision-making with the affected individual(s) and/or
informed of new research. The EBP system is made possible
group(s). Implement the health practice. Appropriate
because systematic reviewers collect and analyze the full body
decision-making integrates the context, values, and prefer-
of new and old studies that address clinically relevant ques-
ences of the individual, community, or population. It also
tions. Systematic reviewers then disseminate their findings to
integrates available resources, including professional
health professionals in the form of succinct summaries that
expertise.
offer EBP recommendations for practicing clinicians.
Step 5: Analyze the new health practice and adjust practice
Systematic review methodology includes a series of steps,
accordingly. Evaluate implications for future decision-
including the formulation of a structured PICOT question
making, disseminate the results, and identify new infor-
that specifies the target population (P), candidate intervention
mational needs.
(I) to be evaluated, comparator (C) intervention, patient
outcome (O) of interest, and over what time frame (T) the
outcome is to be assessed. After formulating the PICOT ques- Client/community
tion, the systematic reviewer develops a comprehensive and assessment Ask
unbiased protocol whose objective is to identify research that
addresses the question. Once the relevant studies have been
acquired, a decision about whether to include them in the
Analyze and
review can be made relative to protocol entry and exclusion adjust
criteria. Included studies are then critically appraised for meth-
(evaluation, Acquire
odological quality, and their data extracted and synthesized to The 5 steps of
dissemination,
reach an answer to the question at hand. Synthesis is some- and follow-up) evidence-based
times performed quantitatively, if the included interventions behavioral practice
and study designs are sufficiently homogeneous; alternatively,
synthesis can be performed qualitatively. Increasingly, system-
atic reviews constitute a requisite basis for EBP guidelines and
Apply
health policies.
The third role that health professionals can play is that of Appraise
the clinician. Assuming one of the most complex and chal-
lenging roles in EBP, the clinician extracts and uses data Figure 4 The 5As approach of EBP.
336 Evidence-Based Practice

Competencies Analyze and Adjust

Ask EBP health professionals participate in continuous quality
improvement. After initiating an intervention that aggregate
EBP health professionals ask important, practice-relevant ques-
research suggests is evidence based, the clinician analyzes change
tions. They know how to translate their information needs into
and adjusts intervention accordingly. As such, the adaptation of
well-formulated, answerable questions. Further, they differen-
interventions to changing individuals in changing contexts over
tiate among various types of practical questions, including
time is at the core of EBP’s transition between the Apply and the
assessment, intervention, prognosis, harm, cost-effectiveness,
Analyze and Adjust. In other words, one initially applies the best
and seek the best type(s) of evidence to answer each kind of
‘one size fits all’ treatment based on systematic review or aggre-
question.
gate evidence. Subsequently, the adaptation of treatment
becomes individualized based on the person’s own unique
Acquire response to the sequence of offered treatments.
EBP health professionals answer their questions by efficiently
and effectively searching for the best available evidence. Specif- Methodological and Practical Challenges
ically, EBP health professionals understand how to seek
answers to their questions by accessing clinical guidelines Despite the past decades’ great strides toward acceptance and
and systematic reviews of research on health procedures. full implementation of EBP, continued barriers remain. Rigor-
They know the difference between primary and secondary ously designed research studies are expensive and take time
(synthesized) research evidence, and can translate questions to complete. Often, research findings are simply lacking or
into efficient search plans. They can use available technology insufficient to provide a basis for policy and practice decisions.
and information systems to stay up-to-date regarding research Gaps in the existing evidence base are especially noteworthy in
relevant to their questions. areas of nondrug treatment interventions and preventive care
(Maciosek et al., 2006; Moyer et al., 2005). The U.S. Preventive
Services Task Force (USPSTF) was created by the U.S. Depart-
Appraise
ment of Health and Human Services in 1984 to address this
EBP health professionals critically appraise evidence based on challenge. The Guide to Clinical Preventive Services, which
its quality and applicability to the specific population and appraises systematic reviews of research graded on its evidence
circumstances at hand. When evaluating research on interven- quality was created to allow governing bodies to identify effec-
tions, it is important to consider both internal and external val- tive evidence-based preventive services (Woolf and Atkins,
idity. Internal validity represents the extent to which research 2001). The evidence reviewed in the current Guide provides
was designed and conducted in a way that enables change to the basis for all preventive services mandated by the Affordable
be causally attributed to the intervention as opposed to extra- Care Act to be covered by insurance without copays. Even so,
neous variables. External validity reflects whether characteristics the evidence about many preventive care practices earns a grade
of the research population or intervention context can be gener- of ‘i’ for insufficient evidence. As such, the state of the science
alized to the current population, interventionist, or circum- too often fails to accommodate the demands of policy-makers
stances. Applicability refers to the clinician’s judgment and health professionals.
vis-à-vis the fit of the evidence with the circumstances. Some have gone so far as to challenge the utility and rele-
In terms of specific competencies, EBP health professionals vance of RCTs as the gold standard research design for evalu-
know the strengths and weaknesses of different kinds of ating intervention effectiveness. Beyond the expense and
research evidence for answering different kinds of health ques- duration of RCTs, other criticisms allege an overemphasis on
tions. They can evaluate the quality and strength of primary internal validity (freedom from bias) over external validity
research evidence based on study design and execution. They (sample representativeness, generalizability) (Altman et al.,
understand how to synthesize research evidence and how to 2001). Other challenges are that RCT designs are sometimes
evaluate the quality and strength of evidence in systematic not feasible to implement when, for example, policy-makers
reviews and practice guidelines. They can identify gaps in or communities decline to accept potential random assignment
evidence that suggest future research. Finally, they evaluate to a control condition.
the applicability of the evidence for a particular individual, Another ongoing tension is that some clinicians chafe under
community, or population. the perceived restrictions that EBP imposes on professional
autonomy. While they may appreciate research-tested practices
as useful tools, they regard treatment as something of an art
Apply
form and prefer being given the creative license to try out
Finding the best available research evidence is one thing. and develop novel treatment tactics. Additionally, health
Applying it is more complex in EBP, because it requires shared professionals may lack training in EBP. Although many training
decision-making between health professionals and those programs train students in the use of specific evidence-based
affected by an intervention. The aim of the shared decision- treatments, few educate students on the EBP process and steps
making is to arrive at an action plan that balances the appli- (Gambrill, 2007a). Discussions are just beginning regarding
cable evidence, the resources available to implement the best the best timing and configuration for EBP in the training curric-
practice, and how the values and preferences of those affected ulum (Jenson, 2007) and optimal teaching techniques
influence the acceptability of the practice. (Gambrill, 2007b; Sackett et al., 2000).
 Evidence-Based Practice 337

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