COMMENTARY

The Essence of Evidence-Based Practice

Tom G. Bartol, NP

Disclosures

September 24, 2018

Are We Overlooking the Crux of Evidence-Based Practice?

With all of the focus on evidence-based practice (EBP), does it really work? Does it really make a difference in outcomes? In a recent review, McCormack and Elwyn[1] clarify a key point about EBP. The goal of EBP is not to improve the population level health outcomes but to give the patient information, based on the evidence as well as the clinician's experience and expertise, to help the patient make a choice based on his or her values and preferences. Population health rarely, if ever, considers patient values and preferences and, the authors maintain, it flies in the face of the fundamental goals and definition of EBP, which is "the integration of best research evidence with clinical expertise and patient values."[2]

Practicing evidence-based medicine should lead to improved patient outcomes. McCormack and Elwyn point out that the outcomes may not be lower disease rates or longer life if the patient chooses not to do something that the population health studies show would prolong life or improve health. The outcome of EBP is that a shared decision was made by the patient with input and shared evidence from the clinician.

Viewpoint

Much of healthcare today is based on evidence-based clinical guidelines, which lead to algorithms for treatment as well as "best practices." The thought is: if we treat a population according to guidelines, everyone will be healthier. But for many treatments, even if evidence-based, the benefits are not extreme; sometimes they are not even clinically significant. There are also risks associated with many treatments and interventions, which will vary with the characteristics and health of individuals. At age 50, a person's risk factors differ from those he or she will have at age 70. An active, healthy individual's risk factors differ from those of a sedentary person with multiple chronic diseases.

Unfortunately, we tend to view clinical guidelines more as mandates, or at least as standards of care. This often prompts us to recommend treatments, medications, or interventions that are outlined in guidelines, which may be based on minimal data (blood pressure, cholesterol level, or blood sugar, for example), or to use a risk calculator, rather than make recommendations on the basis of the health status of the individual and his or her goals and desires. Most guidelines do not take into account baseline health, lifestyle factors, or the real and potential costs and risks associated with interventions.

The clinician's burden is to know the evidence behind the guidelines and to share it, not just to treat everyone according to guidelines. To achieve shared decision-making requires time as well as knowledge, dialogue, and a willingness to allow patients to choose differently from what we might choose for ourselves or recommend to others.

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