How do you apply the evidence? Are you an improver, an adapter, or a rejecter?

It's no secret that many people are struggling to translate research findings into real-world action. Nick Midgley identifies three ways of explaining (and responding to) what I call 'implementation failure' in his editorial, Improvers, Adapters and Rejecters — the Link Between Evidence-based Practice and Evidence-based Practitioners. He supplies great food for thought for anyone interested in how evidence can improve outcomes in health care, business, education, and elsewhere. Although Midgley is a psychotherapist, his analysis is broadly applicable. The article appears in Clinical Child Psychology and Psychiatry ($20US).

Is the goal evidence-based practice, or practice-based evidence? Midgley opens by saying "[T]he culture of ‘evidence based practice’ (EBP) pervades almost every aspect of our public lives. The term is now so pervasive that some critics have spoken of us living in a society in which ‘evidence-based everything’ is the norm.... But EBP is not just about identifying what works for whom. It is also about articulating a new way of working.... But what do such evidence based practitioners actually look like? And how do the ideals of EBP translate into the swampy lowlands of clinical practice?" 

Systematic reviews don't make decisions. People do. Intentionally or not, some of the advocacy of evidence-based ____ seems to imply that systematic reviews are the key to everything. But a systematic review doesn't make a diagnosis, write a recommendation, or make a business decision -- a human being does, based on all kinds of evidence and extenuating factors.

Evidence isn't everything. In health care and in other fields, objective evidence is important, but it's not the only thing. Roy M. Poses, MD put it very well, reminding us that "evidence-based medicine is not just medicine based on some sort of evidence". According to the Sackett definition, "evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research." Besides that, Sackett reminded us to consider client values, preferences, and expectations. (On Evidence Soup, in Oh, dear. Are we going to need a new word for evidence? I discussed the book Evidence-Based To Value-based Medicine, making the case that 'evidence-based' isn't enough.)

But evidence does matter. A lot. Action for Better Healthcare says "One of the most flagrant deficiencies in current medical practice is the relative lack of evidence-based medicine (EBM).... The New England Journal of Medicine (and other peer-review medical journals) regularly contains studies of commonly performed medical procedures demonstrating that the activities lack any patient care value."

Are you an improver, adapter or rejecter? Midgley points out that "Many of those who reject the idea that EBP can be ‘translated’ into clinical practice in any straightforward manner have been drawn to the idea of ‘practice-based evidence’ – a phrase that deliberately plays with the very terms offered by the EBP movement itself." He identifies three categories of people "who write about the difficulties of translating research findings into clinical practice":

1. On one end are rejecters, those who see the evidence-based practice movement as an "outrageously exclusionary and dangerously normative approach promoting dependency on pre-interpreted, pre-packaged sources”. (Prevention Action sums up the rejecter point of view as "There is no evidence that using an evidence-based approach to health care actually improves outcomes, and plenty of anecdotal evidence that it doesn’t.")
2. Improvers "support the aims and goals of the EBP movement" and want to see it influence real-world practice. For them, the primary issue is better implementation of research findings. They focus on activities such as diffusion, dissemination, knowledge transfer, translation, and spread – believing the best way forward is to identify obstacles that prevent evidence uptake, and find ways around them.
3. Adapters are described by Midgley as moderators – unconvinced that the solution is to overcome barriers, they are looking for fundamental reasons why EBP does not translate. Adapters want to widen the definition of evidence. (Amen to that.) For them, the "very definition of ‘evidence’ being used is far too restrictive, with a high value put on ‘context-free’, ‘scientific’ evidence (exemplified by the randomized controlled trial), in which the internal validity of the research design itself is given priority over the external validity of the findings.” Adapters believe smaller-scale, qualitative research should receive more attention -- and that we need better ways to produce meta-analysis of qualitative findings.

Where do we go from here? Some groups use the term 'evidence-informed' (such as the World Health Organization's Evidence-Informed Policy Network), which is a good description of what many of us are trying to accomplish -- but IMO that sounds even more egghead than 'evidence-based'. For now, I think I'll go with 'evidence-guided'.

Comments

[Howard]

Thanks for this post Tracy;
My library resources don't have this yet, but I'm glad to get a preview from you and hope to read it in full soon. It sparked a lot of thought about moving away from a positivist idea of EBP. I responded at length on my blog.
http://howardjohnson.edublogs.org/2009/08/07/more-on-the-research-practice-gap-and-evidence-based-practice/