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Article Excerpt
The concept of evidence-based practice (EBP) has assumed a central position in health and behavioral health care disciplines. Frequently defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71), EBP has been described as "a movement, like the outcomes movement before it, of scientists, public officials, private payers, and advocacy groups that seek to establish a new knowledge regime in health services" (Tanenbaum, 2005, p. 163). Originating from the medical field in 1991, the term evidence-based medicine was established to ensure that medical research was systematically evaluated in a manner that could "inform medicine and save lives and that is superior to simply looking at the results of individual clinical trials" (Wampold & Bhati, 2004, p. 564). Soon after, the field of psychology paralleled these efforts with the development of empirically supported treatments by the American Psychological Association (APA, 1995). These are considered efficacious treatments for specific psychological disorders based on rigorous research (Chambless & Hollon, 1998; Wampold & Bhati, 2004). The APA's Division 12 (clinical psychology), for example, has published a list of 71 psychological treatments that are empirically validated (Chambless & Ollendick, 2001).
Today, EBP has permeated a wide array of health and allied health care disciplines as evidenced by several special issues published in psychology and healthcare journals. One driving force behind EBP is the financial pressure associated with the U.S. health care system. In response to skyrocketing health care costs, efforts have been underway to carefully review how resources are used and spent, to consolidate services, and to restructure reimbursement methods. The emergence of EBP in all facets of health care is deeply connected to both financial viability and efficiency of staff and resources. Health care administrators need to know what works, for whom, and in what situation, as financial constraints and efficiency are guiding forces in service delivery. The use of clinical practice guidelines and clinical pathways (which document a series of effective practices) reflect the joining of EBP and managed care business practices (Cliff, Harte, Kirschling, & Owens, 2004).
The EBP movement should not, however, be viewed only from a financial viability and management standpoint. All rehabilitation and health professionals should have an interest in delivering the best possible services to their clients, based on the best clinical practices available from the research evidence whenever possible, if there is evidence that certain practices are more effective and lead to better outcomes for rehabilitation clients, then rehabilitation professionals have reason to be interested in what has been demonstrated to work well. EBP guidelines may guide clinicians to pay attention so they can be the most effective professionals possible. EBP may also help document quality services for accreditation and performance reviews. Programs may want to market their services to potential clients indicating that they carefully monitor and implement the most current best practices.
The EBP movement does have some controversy, even though it fits nicely with the financial efficiency practices of managed care organizations since it makes intuitive sense for professionals to use practices that have been deemed effective. EBP has evoked debates surrounding the reliance on "best evidence" to drive service delivery because there is not always agreement on "the evidence". Questions regarding what constitutes quality research, how to best apply research evidence, and how to define effectiveness, recur throughout the literature (Tanenbaum, 2005). Another question relates to whether medical trial models fit with behavioral sciences. Randomized clinical trials (RCTs), the "gold standard" for scientific evidence in medicine, may not be the best form of evidence for rehabilitation and other behavioral sciences, because RCTs may not take into account the complexity of actual clinical populations and settings that are critical in behavioral sciences (Wampold, 1997). Conversely, "sweeping condemnations of EBP stand up poorly to a fundamental question: If not evidence, on what should clinicians base their practice? Too often the answer is anecdote, instinct, or training" (McCabe, 2004, p. 572).
Of particular interest are the effects of the EBP movement on the field of rehabilitation. The rehabilitation community's historical emphasis on program evaluation and corresponding empirical research (Corthell & VanBoskirk, 1988; Emener, 1991; Houser, Hampton & Carriker, 2000; McAlees & Menz, 1992; Rubin & Roessler, 1995) should position our field to adapt to this health care climate. Nonetheless, there are a number of challenges that our field faces with respect to implementing EBP. First, while the field of rehabilitation has a strong history of utilizing clear, functional outcomes, it has produced less empirical research on the interventions and process variables that contribute to these outcomes. Our research base is predominantly non experimental, or at best, quasi-experimental, which does not position the field well to offer "best evidence" to those making health care decisions (Bolton, 2004). Johnston, Stineman, and Velozo, (1997) have argued that the complex nature of rehabilitation, both in service delivery and population, makes process research challenging. Specifically, rehabilitation encompasses a broad scope of services, spans the medical-vocational rehabilitation continuum from acute care to community based services, and is provided by professionals from an array of disciplines (e.g., nursing, social work, and rehabilitation counseling) for individuals with diverse and complex impairments and disabilities. The process typically involves a range of personal and environmental processes and the interactions thereof, making it difficult to determine which aspects of service delivery contribute to which outcomes. In fact, multiple services may actually be necessary to reach many outcomes.
A second challenge is the purported "atheoretical" nature of our discipline and the field's historical reliance on a uni-dimensional outcome system; both of these characteristics can lead to restricted and less credible findings (Bellini & Rumrill, 2002; Pransky & Himmelstein; 1996a & b; Rubin & Roessler, 1995; Wright, 1980). The purpose of this paper is to offer rehabilitation professionals up-to-date information about the defining characteristics and available resources of EBP, describe the critical issues that surround this movement, and discuss the implications of this movement for the field of rehabilitation.
Evidence Based Practice
The literature is replete with definitions of EBP. Simply stated, EBP is the process of applying research to practice. Dawes et al. (2005) described the critical elements of EBP as including health care decisions that are based on the best available, valid, up-to-date, and relevant evidence that involves those receiving and providing care within the context of available resources. Typically, the EBP process is described with the following four steps: (a) formulating a question from a clinical problem; (b) systematically retrieving the best evidence available; (c) critically appraising evidence for validity, clinical relevance, and applicability; and (d) implementing useful findings in clinical practice (DePalma, 2002; Parkes, Hyde, Deeks, & Milne, 2001; Richardson, Wilson, Nishikawa, & Hayward, 1995) An additional component of the EBP process often cited in the literature is the ongoing evaluation of outcomes. [According to McCabe (2004), the value of outcome data is only as strong as the outcomes themselves, and is therefore critical when comparing treatment effectiveness.
In the first step, typical questions posed are related to a specific population, intervention, or outcome (Melnyk & Fineout-Overhold, 2005). For...
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