Clinical Interventions

What is Evidence-Based Practice?

This first article of a three-part series explores what evidence-based practice is, why it matters for mental health clinicians, and how to ask a well-built clinical question.

By Mental Health Academy 2023-08-25 03:57:50

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This first article of a three-part series explores what evidence-based practice is, why it matters for clinicians, and how to ask a well-built clinical question.

Read part two here.

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Introduction

Evidence-based practice (EBP) is an approach to clinical decision-making that is based on evidence-based medicine (EBM) (Hoffman et al., 2017). The term “EBM” was first coined by Gordon Guyatt at McMaster University in Canada in the early 1990s (Guyatt, 1991), and later defined by his mentor, David Sackett, and colleagues as: “… the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual clients” (Sackett et al., 1996).

Prior to the EBM movement, the practice of medicine was more of an art than a science with doctors relying on what they were taught as medical students, the expert opinions of older colleagues, and on their own clinical experience to make decisions (Hoffman et al., 2017). However, these sources of information were frequently out-of-date, wrong or biased.

The EBM movement emerged in response to many doctors failing to integrate current evidence from scientific research into their decision-making. The initial focus of EBM was thus on educating clinicians in how to understand and use published literature to optimise clinical care. Over time, EBM evolved beyond critical appraisal of the evidence to include shared decision making, incorporating client values and preferences.

The significant changes EBM brought to client care cannot be overstated. In a recent publication in the prestigious medical journal The Lancet, titled “Progress in evidence-based medicine: A quarter century on”, Guyatt and a colleague offer the following reflection:

“EBM’s enduring contributions to clinical medicine include placing the practice of medicine on a solid scientific basis, the development of more sophisticated hierarchies of evidence, the recognition of the crucial role of client values and preferences in clinical decision making, and the development of the methodology for generating trustworthy recommendations” (Djulbegovic & Guyatt, 2017).

What is Evidence-Based Practice?

Although EBM originated within the medical profession, similar approaches to client care have since been adopted by other health professions and are referred to as evidence-based practice (EBP) or evidence-based health care (EBHC) (Alper & Haynes, 2016; American Psychological Association, 2021; Dusin et al., 2023).

The American Psychological Association’s definition of evidence-based practice in psychology (EBPP) builds on Sackett et al.’s earlier conceptualisation:

“Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences” (American Psychological Association, 2005).

Best available research means clinically relevant research drawn from studies with the least possible bias. Bias occurs when there is a difference between what is measured and the true value. EBP uses the “best available” evidence because the “best possible” may not be available or appropriate. Clinical expertise refers to the use of clinical skills and past experience to facilitate accurate diagnosis and the most appropriate choice of therapy. Client characteristics, culture and preferences reflect the client’s clinical condition, individual concerns, preferences, and expectations (Clinical Information Access Portal, n.d.).

The ‘whys’ of Evidence-Based Practice

The fundamental ‘why’ of evidence-base practice is to optimise client care and outcomes (Hoffman et al., 2017).EBP allows mental health practitioners and clients to make informed decisions; that is, to select assessments and treatments that have been shown to be effective through rigorous scientific research.

Additionally, EBP enhances the professionalism and accountability of the mental health profession:

“Evidence-based practice has an important role in facilitating our professional accountability… As part of providing a professional service, it is our responsibility, whenever possible, to ensure that our practice is informed by the best available evidence… Evidence-based practice promotes an attitude of inquiry in [mental] health professionals and gets us thinking about questions such as: ‘Why am I doing this in this way?’ ‘Is there evidence that can guide me to do this in a more effective way?’” (Hoffman et al., 2017).

The ‘how’ of Evidence-Based Practice: The 5 A’s model

Rather than being a vague concept that is difficult for mental health professionals to incorporate into everyday clinical practice, the EBP process is quite structured. The 5A’s model (Figure 1) provides a systematic approach.

Figure 1. The 5A’s model of EBP.

Step 1: Ask a well-built clinical question

The process begins with the recognition that you have a question that requires clinical evidence, such as a query about a treatment or assessment method. A good clinical question relates directly to the client or problem at hand and is phrased in a way to facilitate the search for an answer. In other words, a good clinical question is searchable and answerable.

The PICO (sometimes PICOTT) framework and mnemonic is a useful guide (Duke University Medical Center Library & Archives, 2023):

  • Patient, population or problem: How would you describe a group of patients similar to yours? What are their most important characteristics? E.g. primary problem, co-existing conditions, age, sex, ethnicity.
  • Intervention: What do you want to do with this client, i.e. what intervention or assessment method are you considering?
  • Comparison: What is the main alternative being considered, if any? This could be standard/usual therapy, another treatment or no treatment at all. In the case of assessments, the comparison could be a different diagnostic tool.
  • Outcome: What are you trying to affect, improve or measure? What are you trying to do for the client e.g., relieve or eliminate symptoms, improve function or assessment scores?
  • Type of Question: Is this a question about treatment, diagnosis, screening, aetiology or prognosis?
  • Type of Study Design: Note: the type of clinical question will often determine the most appropriate study design e.g. systematic review / randomised controlled trial / cohort study / case-control study.

For an intervention/therapy/treatment question, a helpful template is:

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C)?

For an assessment/diagnostic method question, a template is:

Are (is) _________ (I) more accurate/acceptable/affordable in diagnosing ________ (P) compared with ______ (C) for _______ (O)?

Examples of good clinical questions include:

  • Among adults with major depressive disorder (P), how does mindfulness-based stress reduction (I) compare to standard cognitive behavioural therapy (C) in terms of reducing depressive symptoms (O)?
  • Among adolescents engaging in self-harming behaviours (P), does dialectical behaviour therapy (I) lead to a greater reduction in self-harm incidents (O) compared to supportive psychotherapy (C)?
  • In children with suspected autism spectrum disorder (P), does the use of the Autism Diagnostic Observation Schedule (ADOS) (I) compared to clinical judgment alone (C) result in more accurate and reliable diagnoses (O)?
  • In adolescents with possible attention-deficit/hyperactivity disorder (P), what is the diagnostic accuracy of the Conners Comprehensive Behavior Rating Scales (CBRS) (I) versus teacher and parent interviews (C) in identifying ADHD cases (O)?

In our follow-up article, we will consider Step 2: Acquire the evidence including a description of various study designs.

Key takeaways

  • Evidence-based practice (EBP) involves integrating the best available research evidence with clinical expertise and client values to inform clinical decision-making.
  • EBP improves client outcomes and ensures professional accountability.
  • The 5A process includes formulating a clinical question, searching for evidence, critical appraisal, integrating evidence with clinical expertise and client factors, and auditing outcomes.
  • Good clinical questions are searchable and answerable. PICO and PICOTT are useful frameworks to guide the formulation of clinical questions. P refers to the patient, population or problem; I represents the intervention; C is the comparison; O is the outcome; T is the type of question; and T is the type of study design.

References

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