Evidence Based Practice

BY DR.ABSAR
ULLAH KHAN
Evidence based practice
The integration of individual clinical expertise
with the explicit and judicious use of current
best external evidence when making decisions
concerning patient care.
History of evidence-based
health care
The term ‘evidence-based medicine’ was first introduced
in 1992 by a team at McMaster University,
Canada, led by Gordon Guyatt (Evidence-Based
Medicine Working Group 1992). They produced a
series of highly influential guides to help those teaching
medicine to introduce the notion of finding,
appraising and using high-quality evidence to
improve the effectiveness of the care given to
patients (Guyatt et al 1994, Jaeschke et al 1994,
Oxman et al 1993).
Why did the term evolve? What
were the drivers?
There had been growing concern in some countries
that the gap between research and practice was
too great. In 1991, the Director of Research and
Development for the Department of Health in
England noted that ‘strongly held views based on
belief rather than sound information still exert too
much influence in health care’ (Department of
Health 1991).
Why did the term evolve? What
were the drivers?
High-quality medical research was
not being used in practice even though evidence
showed the potential to save many lives and prevent
disability. For example, by 1980 there were sufficient
studies to demonstrate that prescription of
clot-busting drugs (thrombolytic therapy) for people
who had suffered heart attacks would produce a significant
reduction in mortality.
Why did the term evolve? What
were the drivers?
But in 1990 thrombolytic therapy was still not recommended
as a routine treatment except in a minority of medical
textbooks (Antman 1992). Similarly, despite
high-quality evidence that showed bed rest to be
ineffective in the treatment of acute back pain, physicians
were still advising patients to take to their
beds (Cherkin et al 1995).
Why did the term evolve? What
were the drivers?
Another driver was the rapidly increasing volume
of literature. New research was being produced too
quickly for doctors to cope with it. At the same time,
there was a recognition that much of the published
research was of poor quality. Doctors had a daily
need for reliable information about diagnosis, prognosis,
therapy and prevention (Sackett et al 2000).
Why did the term evolve? What
were the drivers?
One way of dealing with the growing volume of
literature has been the development of systematic
reviews, or systematically developed summaries of
high-quality evidence.
In 1992 the Cochrane Collaboration was established. The
Cochrane Collaboration’s purpose is the development
of high-quality systematic reviews, which are
now conducted by 52 Cochrane Review Groups, supported
by 26 Cochrane Centres around the world.
The Collaboration has had a huge impact on making
high-quality evidence more accessible to large numbers
of people.
Why did the term evolve? What
were the drivers?
One of the early drivers of evidence-based physiotherapy
was the Department of Epidemiology at
the University of Maastricht in the Netherlands.
Since the early 1990s this department has trained
several ‘generations’ of excellent researchers who
have produced an enormous volume of high-quality
clinical research relevant to physiotherapy.
Why did the term evolve? What
were the drivers?
In 1998 the precursor to this book, Evidence-Based
Healthcare:
A Practical Guide for Therapists (Bury & Mead
1998), was published, providing a basic text to help
therapists understand what evidence-based practice
was and what it meant in relation to their clinical
practice.
And from 1999 PEDro, a database of
randomized trials, has given physiotherapists easy
access to high-quality evidence about effects of
intervention.
Why did the term evolve? What
were the drivers?
Today, most physiotherapists have heard of
evidence-based practice, and evidence-based practice
has initiated much discussion and also some
skepticism. Some feel the concept threatens the
importance of skills, experience and practice knowledge
and the pre-eminence of interaction with individual
patients.
Steps for practising evidence-
based
physiotherapy
Evidence-based practice involves the following steps
(Sackett et al 2000):
Step 1 Converting information needs into
answerable questions.
Step 2 Tracking down the best evidence with
which to answer those questions.
Step 3 Critically appraising the evidence for its
validity impact and applicability.
Step 4 Integrating the evidence with clinical
expertise and with patients’ unique biologies,
values and circumstances.
Step 5 Evaluating the effectiveness and efficiency
in executing steps 1–4 and seeking ways to
improve them both for next time.
5 steps
• Ask: Convert the need for information into an answerable
question.
• Acquire/ Find: Track down the best evidence with which
to answer that question.
• Appraise: Critically appraise that evidence for its validity
and applicability.
• Apply: Integrate the critical appraisal with clinical
expertise and with the patient's unique biology, values,
and circumstances.
• Analyze and Adjust: Evaluate the effectiveness and
efficiency in executing steps 1-4 and seek ways to improve
them both for next time.
 FORMS OF EVIDENCES

Published Research

Patients Records

Clinical Recall
 The “best” evidence depends on the type
of clinical question
1. What are the phenomena/thoughts?

2. What is frequency of the problem? (FREQUENCY)

3. Does this person have the problem? (DIAGNOSIS)

4. Who will get the problem? (PROGNOSIS)

5. How can we improve the problem?

(INTERVENTION/THERAPY)
 DESIRABLE EVIDENCE

DESIRABLE/ NOT MANDATORY

The study address specific clinical question the PT is trying to

answer

Similar subjects in the study

Study published in peer-reviewed medium (paper, electronic)

Context of the study/ technique of interest are consistent with up to

date health care
 The Barriers to EBP

 Attitude of question & inquiry

 Know-how in finding, appraising, and
applying evidence
 Information Resources on tap
 Lack of Time
 Evidence based physical
therapy
EBPT is physical therapy
informed by relevant, high
quality clinical research
 The Cochrane Collaboration (CL) for example is an
international multidisciplinary network of individuals and
institutions that disseminates critical reviews of health care
research to promote Evidence-Based Practice
(Silagy and Lancaster, 1995).

The Collaboration, named after the late Archie Cochrane to

acknowledge his justified criticism of the health professions
for their lack of organized, updated, systematic reviews of
relevant research (Chalmers and Haynes, 1995) , disseminates
reviews that represent secondary sources, or pre-appraised
evidence (Guyatt et al, 2000) .