Evidence-based practice: what constitutes evidence?

Evidence-based practice, or evidence-based medicine (EBM), has been a buzzword within the health professions for several years, following the business sector’s focus over the past two decades on the need to define best practices in business. It has long been a value that research would ultimately give direction in providing health care that is as effective, safe, and economical as possible. Basic research is far removed from clinical application. For example, basic research might entail the confirmation of a clinical phenomenon, the synthesis of a new molecule, or the identification of a new hormone receptor. It is in the realm of applied research, in which those foundational basic findings are built on and used to achieve desired outcomes, that evidence-based practice is determined. One definition of evidence-based practice is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, pp. 71-72). The Agency for Healthcare Research and Quality (AHRQ), which can be accessed at www.ahcpr.gov, has assumed a leading role in promoting evidencebased practice as a way to reduce what has been described as an epidemic of errors in patient care in the United States. Included in the AHRQ’s legislative mandate is support of synthesis of scientific clinical and behavioral studies on particular treatments and technologies and widespread dissemination of resulting reports. These research findings, syntheses, and guidance are intended to assist providers, clinicians, payers, patients, and policy makers in making evidence-based decisions regarding the quality and effectiveness of health care. One excellent, consumer-friendly example is AHRQ’s Web page on how consumers can reduce the risk that they will be exposed to medical error (20 Tips, 2000). Readers will note that the Web site is not heavily laden with research terminology, yet it is a synthesis of the best information available on this topic. Another AHRQ example pertinent to nurses in HIV/ AIDS care focuses on management of dental patients who are HIV positive (Management of Dental Patients, 2001). Three issues were addressed through an extensive review of literature included within the past 12 months within the MEDLINE and EMBASE databases and the Cochrane Collaboration Library: risks to HIV-positive patients related to invasive oral procedures, oral conditions as markers or indicators of change in HIV status (i.e., seroconversion and immunosuppression), and the efficacy or effectiveness of antifungal treatments (prophylactic and curative) for oral candidiasis in HIV-positive patients. The analysis and conclusions are provided, along with questions for future research. Clinicians are given the best knowledge to date as well as suggestions for where their own research might be focused. This clearly conveys the important concept that knowledge is ever changing. The New York Academy of Medicine in partnership with the Evidence-Based Medicine Committee of the American College of Physicians, New York Chapter, received a grant from the National Institutes of Health