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Evidence-based Decision Making: Introduction and Formulating Good Clinical Questions

Course Number: 311

EBDM Skills and the 5-Step Process

The principles of EBDM methodology are based on the abilities to find, critically appraise, and correctly apply current evidence from relevant research to decisions made in practice so that what is known is reflected in the care provided. The EBDM skills and 5-step process are outlined in Table 3.

Table 3. Skills needed to apply the EBDM Process.2

  1. ASK: Convert information needs/problems into clinical questions so that they can be answered.
  2. ACCESS: Conduct a computerized search with maximum efficiency for accessing the best external evidence with which to answer the question.
  3. APPRAISE: Critically appraise the evidence for its validity and usefulness (clinical applicability).
  4. APPLY: Apply the results of the appraisal, or evidence, in clinical practice.
  5. ASSESS: Assessing the process and your performance.

The following procedures provide an overview of the five steps and skills involved in establishing an evidence-based practice.

  1. Converting information needs/problems into clinical questions so they can be answered – the PICO process.

    Asking the right question is a difficult skill to learn, yet it is fundamental to evidence-based practice. The process almost always begins with a patient question or problem. A "well-built" question should include four parts, referred to as PICO that identify the Patient Problem or Population (P), Intervention (I), Comparison (C), and Outcome(s) (O).2 These parts, or components provide the key terms for step two.

  2. Conducting a computerized search with maximum efficiency for accessing the best external evidence with which to answer the question. This type of search requires a shift in thinking. Finding relevant evidence requires conducting a focused search of the peer-reviewed professional literature based on the appropriate methodology. Online databases and software that enable quick access to the literature have made it easier to locate relevant clinical evidence.

    Knowing what constitutes the highest levels of evidence and how to apply evidence-based filters and limits will let you search the literature with maximum efficiency. It is the combination of technology and good evidence that allows healthcare professionals to apply the benefits from clinical research to patient care.

    To assist professionals in keeping up with the literature and in making it possible to quickly find needed information without leaving your location, online access to MEDLINE via PubMed,, is provided by the National Library of Medicine (NLM). See the course, Strategies for Searching the Literature Using PubMed, for step-by-step guidance.

  3. Critically appraising the evidence for its validity and usefulness (clinical applicability). Once you have found the most current evidence, the next step in the EBDM process is to understand what you have and its relevance to your patient and the PICO question. Resources are available to help you critically appraise individual research studies and meta-analyses or systematic reviews. They consist of a worksheet with a structured series of questions that can help you determine the strengths and weaknesses of how a study was conducted and how useful and applicable the evidence is to the specific patient problem or question being asked.17-19

  4. Applying the results of the appraisal, or evidence, in clinical practice. Once the methods are determined to be valid, the fourth step is to determine if the results (potential benefits or harms) are important. This is achieved by looking at whether there is an association between specific treatments and outcomes or exposures, the strength of that association, and the condition of interest, i.e., your patient problem or question. Understanding how to present statistical information to patients in a clear and unambiguous manner will help in making good patient care decisions. Differences between groups in clinical trials are generally straight forward when expressed in terms of the mean values; whereas, results presented as proportions, such as relative risk reduction, absolute risk reduction, odds ratio and numbers needed to treat (NNT), are more challenging to understand. Also, understanding the difference between statistical and clinical significance will help you in translating and determining if the findings apply to your patient.

  5. Assessing the process and your performance.

    The final step in EBDM is evaluation of the effectiveness of the process. Mastering the skills of evidence-based decision making takes practice and reflection and a clinician who is new to the steps should not be discouraged by early difficulties encountered. Evaluating the process of EBDM may include a range of activities such as examining outcomes related to the health/function of the patient and patient satisfaction. Self-evaluation of developing skills is a most critical aspect in mastery of EBDM. With an understanding of how to effectively use EBDM, you can quickly and conveniently stay current with scientific findings on topics that are important to you and your patients.