Evidence-Based Practice: Research Guide | 5 Steps of EBP

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5 Steps of EBP

1. Ask: Convert the need for information into an answerable question.
2. Find: Track down the best evidence with which to answer that question.
3. Appraise: Critically appraise that evidence for its validity and applicability.
4. Apply: Integrate the critical appraisal with clinical expertise and with the patient's unique biology, values, and circumstances.
5. Evaluate: Evaluate the effectiveness and efficiency in executing steps 1-4 and seek ways to improve them both for next time.

1. ASK: Using PICO

Formulating a strong clinical question is the first step in the research process. PICO is a way of building clinical research questions that allow you to focus your research, and to create a query that better matches most medical databases.

• Patient – Describe your patient or population. What are the most important characteristics? Include information on age, race, gender, medical conditions, etc.
• Intervention – What is the main intervention or therapy you are considering? The can be as general as treat or observe, or as specific as a specific test or therapy.
• Comparison Intervention – An alternative intervention or therapy you wish to compare to the first.
• Outcome – What are you trying to do for the patient? What is the clinical outcome? What are the relevant outcomes?

Example: In a (describe patient) can (intervention A) affect (outcome) compared with (intervention B)?

• In a 50 year old man with diabetes is weight loss and exercise or medication better at maintaining healthy blood sugar levels?
  • Patient - 50 yr old man with diabetes
  • Intervention - weight loss and exercise
  • Comparison - medication
  • Outcome - maintaining blood sugar levels

  2. FIND: Formulate a Search Strategy

  Think about the keywords for each of the PICO parts of the clinical question.

  Sample Question: Is prophylactic physical therapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?

  The PICO parts with keywords for this question would look like this:

  Parts of Question	Clinical Scenario	Keywords
  Patient Population	patients undergoing upper abdominal surgery	upper abdominal surgery
  Intervention	prophylactic physical therapy	prophylactic physical therapy
  Comparison (if any)	no prophylactic physical therapy	none
  Outcome	prevent post-operative pulmonary complications	prevent pulmonary complications
  Type of Study	RCT	Randomized Control Study

  You might also see PICO with an added T. The T often stands for either “time” or “type of study.” Time helps you consider the timeframe of an intervention or outcome, while type of study is a way to define the types or levels of evidence that you will need in order to answer your question.

  3. APPRAISE: Evidence & Evaluation

  Different types of information provide different standards or levels of evidence. These levels depend on things like a study's design, objectives, and review process. You may be familiar with a pyramid diagram showing a hierarchy of types of evidence. Often included in pyramids of evidence are the following types of information:

  

  • Secondary studies and filtered or pre-appraised evidence:
    • Clinical practice guidelines—recommendations for applying current medical knowledge (or evidence) to the treatment and care of a patient.
    • Meta-analyses and systematic reviews—an approach to literature reviews that identifies all studies addressing a given research question based on specific inclusion criteria and analyzes the results of each study to produce a summary result.
    • Randomized controlled trials (RCTs)—eligible participants are randomly assigned to study groups to test a treatment against a control group. In blinded trials, the participants and researchers do not know which study group participants have been assigned to.
    • Cohort studies—follow a group of subjects over a period of time to determine the incidence or identify predictors of a certain condition.
    • Case-control studies—compare two groups of subjects, one with the outcome and one without, to identify predictor variables associated with the outcome.
    • Case reports/series, expert opinions, and editorials—reports on individual cases with no control groups involved, opinions based on one person’s experience and expertise

    The pyramid hierarchy places some types of evidence above others in terms of validity, objectivity, and transferability. It’s important to remember, however, that the best type of evidence to answer your research question depends on the nature of your question and what purpose you have for searching for evidence in the first place. Conducting a literature review, for example, is a very different situation than searching for an answer to a specific question about a particular case, patient, or situation.

    Evaluation Criteria:

    • Credibility (Internal Validity)
    • Transferability (External Validity)
    • Dependability (Reliability)
    • Confirmability (Objectivity)

    Credibility: looks at truth and quality and asks, "Can you believe the results?"

    Some questions you might ask are: Were patients randomized? Were patients analyzed in the groups to which they were (originally) randomized? Were patients in the treatment and control groups similar with respect to known prognostic factors?

    Transferability: looks at external validity of the data and asks, "Can the results be transferred to other situations?"

    Some questions you might ask are: Were patients in the treatment and control groups similar with respect to known prognostic factors? Was there a blind comparison with an independent gold standard? Were objective and unbiased outcome criteria used? Are the results of this study valid?

    Dependability: looks at consistency of results and asks, "Would the results be similar if the study was repeated with the same subjects in a similar context?"

    Some questions you might ask are: Aside from the experimental intervention, were the groups treated equally? Was follow-up complete? Was the sample of patients representative? Were the patients sufficiently homogeneous with respect to prognostic factors?

    Confirmability: looks at neutrality and asks, "Was there an attempt to enhance objectivity by reducing research bias?"

    Some questions you might ask are: Were 5 important groups (patients, care givers, collectors of outcome data, adjudicators of outcome, data analysis) aware of group allocations? Was randomization concealed?