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Take a systematic approach to evidence-based practice

This is an excerpt from Management Strategies in Athletic Training, Fourth Edition, by Richard Ray and Jeff Konin.

Evidence-Based Practice

Over the last couple of decades, there has been an increased effort internationally to support assessment techniques and interventions as they relate to all aspects of medicine. The term evidence-based medicine has evolved as an approach to improving practice efficacy. Among other variations of this term are “evidence-based practice” and “evidence-based health care.” Sackett and colleagues (1996), considered one of the forefathers of evidence-based medicine, coined the phrase and defined it as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” When incorporating the evidence into clinical practice, one should use a systematic approach toward reviewing peer research data so that unbiased clinical decision making can occur (Belanger 2002). Steves and Hootman (2004) noted the following reasons for the importance of evidence-based medicine for athletic training:

1. Improvement of care for the patients

2. Promotion of critical thinking

3. Ongoing and continued evaluation of treatment methods

4. Allows for athletic training to further contribute alongside health professions in peer-reviewed published evidence

5. Improved potential for third-party reimbursement

6. Overall enhanced reputation for the profession

The authors have furthermore identified five components of evidence-based medical practice for athletic trainers to adhere to:

1. Define a critically relevant question

2. Search for the best evidence

3. Appraise the quality of the evidence

4. Apply the evidence to clinical practice

5. Evaluate the outcomes of the applied evidence

Watson (in Law 2002) described the relative value of a particular intervention as it relates to the overall cost of providing the service. With reference to five types of economic value (cost–consequence analysis, cost-minimization analysis, cost-effectiveness analysis, cost–utility analysis, and cost–benefit analysis), part of the perceived success of an intervention relates to how the intervention compares in outcomes results to other comparable treatments when the cost per delivery of the intervention is factored in. For example, if two interventions yielded the same result for a patient but one was less costly than the other, the lower-cost intervention would be better to use for the overall population since this could translate into a significantly larger savings of dollars spent for health care. Pharmaceuticals is an area in which this is clearly seen. Many brand-name drugs also have a “generic” equivalent that is approved to provide similar outcomes at a much lower cost to the consumer.

Since evidence-based medicine approaches to clinical care are a relatively new concept in organized health care, many current practitioners were not formally educated about the process and have been forced to learn the importance of the evidence, as well as how to identify and utilize evidence, as part of their professional growth. There is growing support for teaching evidence-based medicine concepts as a standard part of today’s medical and health care curriculum in an effort to promote this style of clinical practice as a learned normative method (Burns and Foley 2005; Cliska 2005). The BOC considers the application of evidence-based medicine in the practice of athletic training a professional responsibility. Similarly, the educational competencies as outlined by NATA include using evidence-based medicine as a foundation for the delivery of care for all entry-level athletic trainers.

One outcome that has been sparingly introduced into clinical practice as a result of evidence-based medicine is the use of clinical practice guidelines, or CPGs. Clinical practice guidelines have been defined by Nicholson (in Law 2002) as “systematically developed statements that assist practitioner and patient decision about appropriate health care for specific clinical circumstances.” Perhaps one of the more well-known CPGs is the one related to the assessment process for an acute ankle injury:

The Ottawa Ankle Rules (OAR)

X-rays are only required if pain exists in the malleolar zone and any one of the following:

  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, or
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or
  • An inability to bear weight both immediately and in the emergency department for four steps.

Challenges With Implementing Evidence-Based Medicine

Despite the need for the profession of athletic training to join all other medical and allied health providers in the implementation of sound, evidence-based practice, not all have embraced the concept in its entirety. The two most common reasons are that (1) a large percentage of athletic trainers are not practicing in a setting that requires oversight of outcomes as they relate to using evidence-based techniques (i.e., reimbursement) and (2) the concept of evidence-based medicine has been formally taught in entry-level athletic training education programs for only the past couple of years. More specifically, the following barriers to successful integration of evidence-based practice in clinical settings have been identified (Haynes and Haynes 1998):

  • Amount and complexity of available research
  • Difficulties in developing evidence-based clinical policies
  • Limited access to evidence for some clinicians
  • Ineffective continuing education programs
  • Challenges with patient compliance

Maher and colleagues (2004) have also described barriers to evidence-based practice specifically in the physical therapy profession, identifying the following reasons behind the barriers:

1. Publication bias, with authors submitting for publication only those studies that have yielded positive outcomes

2. Indexing of journals, as many practicing clinicians do not have access to subscriptions for databases, and many databases do not include trials performed earlier

3. Difficulty of obtaining access to the full text of some published articles

4. Language barriers, as some studies are not published in English

5. Limited number of systematic reviews that assist with assessment of internal validity of the published research

6. Difficulty in translating published studies into clinical practice

7. Difficulty in drawing conclusions from the evidence when conflicting reports are available

8. Difficulties of influencing the integration of the evidence into a patient’s own health care decision-making process

It is clear that much more needs to be done for a complete cultural shift toward universal acceptance of evidence-based medicine to occur. Collaborative efforts toward removing the perceived and real barriers to implementing evidence-based medicine will allow for further advancement of quality health care services based on sound evidence. Furthermore, all scientists, educators, and clinicians will need to come closer to a consensus for rating systems that are used to both evaluate and report the evidence. One important concept that has plagued the profession of athletic training as well as medicine as a whole is the fact that in some cases, positive patient outcomes can be achieved despite the lack of peer-reviewed scientific studies that explain why. A lack of studies to support an assessment or intervention does not in and of itself mean that the approach does not work.

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