Unpacking the Meaning of "Evidence" in Health Care
As readers of this journal would know, over the years, I have commented on many issues underpinning evidence-based practice in health care. These reflections have been as a result of numerous years of researching, teaching, and exploring the concept of evidence-based practice in contemporary health care and what this means for a range of health care stakeholders. A couple of years ago, I had the opportunity to work with the Australian Association of Massage Therapists, the peak body which represents massage therapists in Australia. I led a team of researchers who undertook an umbrella review on the effectiveness of massage therapy for nonspecific low back pain, which was subsequently published.1 One of the drivers for undertaking this umbrella review was the review of the Australian Government Rebate on Private Health Insurance for natural therapies which examined the evidence of clinical efficacy, cost effectiveness, safety, and quality of natural therapies. The findings from the Australian Government review was to then inform the decision on which natural therapies should continue to receive the rebate. While the findings of the review have not been officially released, it is expected, as reported by many local media organisations, that many natural therapies may not be supported by evidence.
While the “so what” for natural therapies in Australia as a result of this review remains unclear, it did highlight an important issue that is worth considering, and that is what do we mean by “evidence”? The term evidence is used quite broadly in many aspects of everyday life including the justice system where it is about determining the facts of a case and establishing true account of events beyond reasonable doubt. In health care, evidence has been defined as part of evidence-based practice, most famously by Sackett and colleagues, and is widely considered to include the constructs of best research evidence, clinical expertise, patient’s morals, values, and beliefs and information from the practice context.
Therefore, in order for a health professional to undertake evidence-based practice, he or she should be able to integrate these fours constructs in a meaningful and efficient manner and informed by sound clinical reasoning. There have been a number of publications over the years which have highlighted the limitations of merely focussing on one construct of evidence-based practice, such the reliance on randomised controlled trials as the only source of best evidence.2,3,4 Furthermore, different health professions may have different understandings of and recognition for what constitutes “evidence” within their professions (such as qualitative research in nursing).5 Furthermore, it is now clear that despite a growing body of evidence, there appears to be persistent evidence-practice gaps in health care, which highlight the challenges and complexities underpinning the implementation of evidence-based practice.6,7,8
It is now 15 years since the Institute of Medicine published the seminal report on “Crossing the Quality Chasm: A New Health System for the 21st Century” in which it highlighted the core needs of health care to be safe, effective, patient-centred, timely, efficient, and equitable.9 In order to achieve this, it set out 10 rules that include evidence-based decision making (in addition to patient focussed, clinical focussed, and systems focused rules).
Therefore, it is imperative that health care decision making, be it practice or policy, should be underpinned by evidence. However, it is important to also recognise that evidence may mean different things to different health care stakeholders and therefore should be balanced, equitable, and relevant. Without such consideration and efforts to unpack the meaning of evidence, we run the risk of perpetuating ongoing evidence-practice gaps as evidence-based practice may, erroneously, be viewed as merely about a single construct (such as research only) and not about bringing together of best research evidence, clinical expertise, patient’s morals, values and beliefs, and information from the practice context.
- Kumar S, Beaton K and Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International Journal of General Medicine 2013, 6: 733–741.
- Kendall S. What do we mean by evidence? Implication for primary health care nursing. Journal of Interprofessional Care 1997, 11(1):23- 34.
- Milanese S. The use of RCT’s in manual therapy – are we trying to fit a round peg into a square hole? Manual Therapy 2011, doi:10.1016/j.math.2011.02.007.
- Silvernail J. Manual therapy: process or product? Journal of Manual and Manipulative Therapy 2012, 20(2):109-110.
- Meadows-Oliver M. Does Qualitative Research Have a Place in Evidence-Based Nursing Practice? Journal of Pediatric Health Care 2009. 23: 352-354.
- Bryant J, Boyes A, Jones K, Sanson-Fisher R, Carey M, Fry R. Examining and addressing evidence-practice gaps in cancer care: a systematic review. Implementation Science 2014, 9:37.
- Evensen AE, Sanson-Fisher R, D’Este C, Fitzgerald M. Trends in publications regarding evidence practice gaps: A literature review. Implementation Science 2010, 5:11.
- Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia 2004, 180: S57-S60.
- National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century, 2000. Washington, United States of America.
Kumar S. Unpacking the Meaning of "Evidence" in Health Care. The Internet Journal of Allied Health Sciences and Practice. 2015 Jan 01;13(1), Article 4.