Evidence-Based Practice

"Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved."

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-Based Practice, Step by Step: Asking the Clinical Question. AJN, American Journal of Nursing, 110(3), 58–61. https://doi.org/10.1097/01.naj.0000368959.11129.79

Evidence-based practice is a process.

The five major steps are:

1. ASK a searchable question
2. AQUIRE information
3. APPRAISE search results
4. APPLY the evidence in practice
5. ASSESS the provided care

de Groot, M., van der Wouden, J. M., van Hell, E. A., & Nieweg, M. B. (2013). Evidence-based practice for individuals or groups: let's make a difference. Perspectives on medical education, 2(4), 216–221. https://doi.org/10.1007/s40037-013-0071-2

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"Information Mastery is the application of the principles of evidence-based medicine concepts and techniques to the day-to-day practice of medical care. The concepts were developed in the early 1990s by Allen F. Shaughnessy, PharmD, MMedEd of Tufts University and David Slawson, MD of the University of Virginia."

Source: Tufts University School of Medicine: Center for Information Mastery. http://medicine.tufts.edu/Education/Academic-Departments/Clinical-Departments/Family-Medicine/Center-for-Information-Mastery.

Information Mastery is based on several concepts:

• Patient-Oriented Evidence That Matters (POEMs) vs. Disease-Oriented Evidence
• Usefulness Equation - determining which information source is most useful to the physician
• Two Tools Are Needed - a reliable source for Point-of-Care at the bedside, and another tool for "keeping up with the literature"
• Clinical Jazz - blending clinical science and the art of medicine as depicted in the EBM Triad

Patient-Oriented Evidence

Seeking outcomes that matter to the patient (and, therefore, to the practitioner) is an important consideration when developing a PICO question and using it to search the literature for research studies.

This kind of evidence is called Patient-Oriented Evidence (POE) and describes outcomes of importance to the patient:

• Improvement of symptoms
• Reduction in pain
• Quality of life
• Cost of the intervention
• Morbidity/Mortality
• Length of stay

POEs are essentially interventions that help patients live longer or better lives. If a POE would change practice, it becomes a POEM (Patient-Oriented Evidence that Matters).

Disease-Oriented Evidence

Patient-oriented evidence is becoming more common, but the medical literature is full of examples of studies that relate Disease-Oriented Evidence (DOE). These studies illuminate the etiology, prevalence and pathophysiology of diseases. They give us insight into the disease process but are less helpful in the clinical management of patients. In fact, in many studies preliminary data were promising or intermediate results looked good, but when real patients and outcomes were measured, results were disappointing or even showed the intervention to be unsafe.

Examples of Disease vs. Patient Oriented Evidence:

DOE: Beta-carotene and vitamin E are good antioxidants

POE: Neither vitamin prevents cancer or cardiovascular disease

DOE: Antiarrythmic drug X is decreases the incidence of premature ventricular contractions on ECGs

POE: Antiarrythmic drug X is associated with an increase in mortality

The differences between DOEs and POE(M)s are important to the concept of EBM and Information Mastery. With today’s rapid increase in the amount of published information, the health care professional’s obligation to stay up to date, and the limits of time, your efforts should focus on identifying, validating and applying POEMs in your practice.