Evidence Based Medicine
What is Evidence Based Medicine
The most commonly used definition for EBM is that "Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research." provided by David Sackett et al in the 1996 article, " Evidence-Based Medicine: What it is and what it isn't" for BMJ. (Full text here)
However, there are some specific points to consider when defining Evidence-Based Practice.
"Evidence-based practice (EBP) refers to the systematic process where-by decisions are made and actions or activities are undertaken using the best evidence available. The aim of evidence-based practice is to remove as far as possible, subjective opinion, unfounded beliefs, or bias from decisions and actions in organisations. Evidence for decisions comes from various sources:
- Peer-reviewed research
- Work-based trial and error testing
- Practitioner experience & expertise
- Feedback from practice, practitioners, customers, clients, patients or systems
Evidence based practice also involves the ability to be able to evaluate and judge the validity, reliability and veracity of the evidence and it’s applicability to the situation in question. This means that there are a series of methods and approaches for developing practice, and that evidence-based practitioners undergo continual development and training as practice develops." (Oxford Review.com)
The Center for Evidence Based Managment (CEBMa) recommends that researchers consider the following questions in regard to published research and evidence. The process of evaluating evidence is known as critical appraisal.
1. Is the evidence from a known, reputable source?
2. Has the evidence been evaluated in any way? If so, how and by whom?
3. How up-to-date is the evidence?
CEBMa offers tools to help appraise research studies in the form of Critical Appraisal Checklists; you can set up a free account to access these resources.
Assessment Tools
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AMSTAR 2AMSTAR stands for A MeaSurement Tool to Assess systematic Reviews. This instrument was developed by the Bruyere Research Institute to assess the methodological quality of systematic reviews.
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CASP (Critical Appraisal Skills Programme)"This set of eight critical appraisal tools are designed to be used when reading research, these include tools for Systematic Reviews, Randomised Controlled Trials, Cohort Studies, Case Control Studies, Economic Evaluations, Diagnostic Studies, Qualitative studies and Clinical Prediction Rule."
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CEBM. Critical Appraisal Tools.Contains useful tools and downloads for the critical appraisal of different types of medical evidence.
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Cochrane Risk-of-Bias tool for Randomized TrialsRoB2 - RoB 2: A revised Cochrane risk-of-bias tool for randomized trials. It is the recommended tool to assess the risk of bias in randomized trials included in Cochrane Reviews. RoB 2 is structured into a fixed set of domains of bias, focusing on different aspects of trial design, conduct, and reporting.
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Dartmouth Biomedical Libraries. Evidence-Based Medicine Worksheets.critical appraisal worksheets for therapy, diagnostic, prognosis, etiology, & qualitative studies, and practice guidelines & systematic reviews
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Duke University Medical Center Library. Evidence-Based Practice: AppraiseCritical appraisal worksheets for therapy, diagnosis, prognosis, qualitative studies, and more.
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Joanna Briggs Institute (JBI). Critical Appraisal Tools"JBI’s critical appraisal tools assist in assessing the trustworthiness, relevance and results of published papers." Includes checklists for 13 types of articles.
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Temple University Library. Critical Appraisal Checklists by Specific Study Design TypeLibrary guide with lists of critical appraisal checklists and tools.
The IOWA Model
Center of Evidence Based Medicine: Study Designs
According to the Center of Evidence Based Medicine, study designs include:
A defined population (P) from which groups of subjects are studied
Outcomes (O) that are measured
Experimental and analytic observational studies also include:
Interventions (I) or exposures (E) that are applied to different groups of subjects
Click here to go to a description of each research study type, including strengths and weaknesses
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Levels of Evidence
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Understanding 'Levels of Evidence'
Developed by the Physiotherapy Association of British Columbia this tutorial explains the levels of evidence, based on research study design, so that you can find the best evidence for your practice using a database
The Funnel
"Evidence-based practice needs an update. To that end, this is the fifth article in our Journal of PeriAnesthesia Nursing series revolutionizing processes for evidence-based practice (EBP). The objective of this series is to identify EBP-related traditions that have been in existence for decades, some of which are outdated, while others are not grounded in evidence, and may just add confusion, poor scholarship, and a workload burden. Since the October 2022 issue of the Evidence into Practice column, we have addressed implementation
failure,1 problems with Patients/Problem/Population, Intervention, Comparison, and Outcome (PICO),2,3 and a need for team science in
EBP work.4 The next step in the EBP process involves assembling, appraising, and synthesizing the best evidence.5 In this column, we examine the common practice of grading evidence according to levels in an evidence hierarchy, also referred to as the evidence pyramid"
What is PICO?
PICO is a mnemonic used to aide the clinician or researcher in identifying the important parts of a well-defined clinical question. This question then provides the basis for a search of medical literature on the question topic.
Elements of a Clinical Question
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Types of Possible Questions in Relation to PICO
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From The American Journal of Nursing
Evidence-Based Practice Part 1 : Developing and Searching the Clinical Question
Evidence-Based Practice, Part 2 : Critical Appraisal of the Evidence
Evidence-Based Practice Part 3 : Implementation
Evidence-Based Practice Part 4 : Disseminating the Evidence and Sustaining the Change
- EBP 2.0: From Strategy to Implementation
- EBP 2.0: Promoting Nurse Retention through Career Development Planning
- EBP 2.0: Data-Driven Precision Implementation Approach
- EBP 2.0: Implementing and Sustaining Change: The STAND Skin Bundle
- EBP 2.0: Implementing and Sustaining Change: The Malnutrition Readmission Prevention Protocol
- EBP 2.0: Implementing and Sustaining Change: The Evidence-Based Practice and Research Fellowship Program
- EBP 2.0: Implementing and Sustaining Change: Implementing Improved Central Line Flushing Practices
The 5 A's
From Ascension WI:
The 5 "A's" will help you to remember the EBP process:
- ASK: Information needs from practice are converted into focused, structured questions.
- ACCESS / ACQUIRE: The focused questions are used as a basis for literature searching in order to identify relevant external evidence from research.
- APPRAISE: The research evidence is critically appraised for validity.
- APPLY: The best available evidence is used alongside clinical expertise and the patient's perspective to plan care.
- ASSESS / AUDIT: Performance is evaluated through a process of self reflection, audit, or peer assessment.
Please note, there are several models for EBP with various named and numbered steps. This guide will detail the first three steps ASK, ACCESS/ACQUIRE, APPRAISE. Some models include a 6th step for DISSEMINATE.
* This box and graphic was created by Diane Giebink-Skoglind of ThedaCare. Used by permission. The graphic is adapted from Melnyk, BM & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best pracatice. (2nd ed.) Philadephia: Wolters-Kluwer/Lippincott Williams & Wilkins.
Levels of Evidence
Level I |
Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or 3 or more RCTs of good quality that have similar results. |
Level II |
Evidence obtained from at least one well designed RCT (eg large multi-site RCT). |
Level III |
Evidence obtained from well-designed controlled trials without randomization (ie quasi-experimental). |
Level IV |
Evidence from well-designed case-control or cohort studies. |
Level V |
Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis). |
Level VI |
Evidence from a single descriptive or qualitative study. |
Level VII |
Evidence from the opinion of authorities and/or reports of expert co |