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Chapter 3

Evidence-Based Practice and Informatics

Evidence-Based Clinical Decision Making

Choices are based on the idea that research-based care improves outcomes.

What intervention will most likely diminish the health problem?

Quality of Care

Is the “degree to which health services to individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

(Institute of Medicine [IOM], 1990)

Quality of Care (Cont.)

Quality of care lags behind knowledge.

Evidence-based practice (EBP) is considered as a solution.

How is EBP a solution?

Agency for Healthcare Research and Quality (AHRQ) Annual Report

Data are gathered from 36 databases.

Healthcare quality in America is suboptimal.

Gap between the best possible and routine care is substantial.

Small gains are being made.

Institute of Medicine (IOM) 2001 Report

STEEEP redesign:

Safe

Timely

Effective (EBP)

Efficient

Equitable

Patient-centered

Evidence Hurdles

VOLUME of literature:

No unaided human being can read, recall, and act effectively on the volume of clinically relevant scientific literature. (IOM, 2001, 25)

FORM of knowledge:

Not every knowledge source is suitable for informing clinical decisions. (ACE Star Model, 2004)

ACE Star Model of Knowledge Transformation

Figure 3-1.

Knowledge Transformation

Is the conversion of research findings from a single research study through a series of stages to impact health outcomes.

Premises of the Star Model

Knowledge transformation is necessary before research results are usable in clinical decision making.

Knowledge is derived from a variety of sources. In healthcare, the sources of knowledge include research evidence, experience, authority, trial and error, and theoretical principles.

The most stable and generalizable knowledge is discovered through systematic processes that control bias, namely, the research process.

Premises of the Star Model (Cont.)

Evidence can be classified into a hierarchy of strength of evidence. The relative strength of evidence is largely dependent on the rigor of the scientific design that produced the evidence. The value of rigor is that it strengthens cause-and-effect relationships.

Knowledge exists in a variety of forms. As research evidence is converted through systematic steps, knowledge from other sources (e.g., expertise, patient preference) is added, creating yet another form of knowledge.

Premises of the Star Model (Cont.)

The form (i.e., package) in which knowledge exists can be referenced to its use; in the case of EBP, the ultimate use is its application in healthcare.

The form of knowledge determines its usability in clinical decision making. For example, research results from a primary investigation are less useful to decision making than a clinical EBP guideline.

Premises of the Star Model (Cont.)

Knowledge is transformed through the following processes:

Summarization into a single statement about the state of the science

Translation of the state of the science into clinical recommendations, with the addition of clinical expertise, the application of theoretical principles, and client preferences

Integration of recommendations through organizational and individual actions

Evaluation of the impact of actions on targeted outcomes

Point 1: Discovery Research

Knowledge produced through primary discovery

Knowledge is in the form of results from a single research study.

Point 2: Evidence Summary

Includes:

Evidence synthesis

Systematic reviews

Integrative reviews

Reviews of literature

Point 3: Translation to Guidelines

Experts are called on to consider the evidence summary, fill in gaps with consensus expert opinion, and merge research knowledge with expertise to produce clinical practice guidelines (CPGs).

For example, research becomes clinical recommendations.

Strength-of-Evidence Rating Hierarchy

Figure 3-2.

Point 4: Practice Integration

Integrate clinical findings into practice.

Can involve change at varying levels.

Individual

Organization

Policy

Point 5: Evaluation

Evaluate the impact of the change:

Redesign of care

Effectiveness of the care in producing desired patient outcomes

Patient outcomes

Population outcomes

Efficiency and cost factors in the care (short- and long-term)

Satisfaction of both providers and patients

Conclusion and Future Directions

The EBP frameworks provide a foundation upon which informatics solutions can be constructed to move evidence into practice.

Information exchange, integrating interoperability standards into vendor products, and data linkage are critical for advancement.