C O L L A B O R A T I V E C A S E M A N A G E M E N T
Principles of Evidence-Based Practice for Case Managers
By Geri Wood, PhD, RN, FAAN
Expert opinion and clinical experience are no longer the only sources for healthcare decision-making. Research evidence is an increasingly
important source, and it is an increasingly common expectation that all health care providers become an integral link in bringing that
clinical research evidence into patient care delivery. Patients have access to information in almost “real time” and, regardless of their
locale or the clinical setting, they and their families want the very best that healthcare practice has to offer them.
With a myriad of responsibilities, and procedural, payer and
policy changes requiring vigilance, it may be overwhelming for the
primary care team to consider evidence-based practice.
Understanding statistics, the ability to evaluate complicated clinical
research studies and the implementation of new protocols may seem
to be assignments outside of a case manager’s already full work day.
However, evidence-based practice need not be overwhelming,
and a degree in Statistics is not required to use clinical evidence
to improve practice. This article will outline the basic principles
required to implement evidence-based practice changes.
WHAT IS EVIDENCE-BASED PRACTICE?
Evidence-based practice relies on the concepts of evidence-
based medicine, but applies more broadly to patient care than
only “medicine.” Evidence-based practice applies broadly to
the spectrum of caregivers on a patient care team. A landmark
article written in 1996 by DL Sackett provided a definition for
evidence-based practice: “Evidence based medicine is the
conscientious, explicit, and judicious use of current best evidence
in making decisions about the care of individual patients. The
practice of evidence based medicine means integrating individual
clinical expertise with the best available external clinical evidence
from systematic research”1 (emphasis added).
While evidence-based practice is not to be confused with
continuous quality improvement (CQI), there is a similarity in the
methodical approach to instigating a process change, evaluating
and assessing the outcome, and drawing conclusions. The CQI
process does not require a research-based search for evidence –
actions are often taken based on analysis of existing, institution-
based process data. There is the potential for overlap, however.
For example, consider a CQI project to reduce length of stay (LOS)
by preventing hospital-acquired catheter infections in a certain
group of patients. This project could easily lead to altering patient
care practices for patients who meet specific criteria, based on
appropriate research and applying evidence to identify “best
practice.” In evidence-based practice, “best practice” is not based
only on expert opinion but is complemented by clinical research
evidence, providing an example of a CQI project that employs
evidence-based practice as well as CQI methodology.
EVIDENCE-BASED PRACTICE SKILLS
One of the most important skills required is the ability to
evaluate research studies regarding the applicability to the
clinical question being investigated. There are five steps to sound,
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evidence-based practice which rely most on analytical skills,
not statistics. The five steps are:
• ASK – What aspect of my clinical practice is
under investigation?
• GATHER – Collect the best evidence,
• ASSESS AND APPRAISE – Evidence relevant
to the question and population of interest,
• ACT – Integrate and implement, and
• EVALUATE – Assess outcome(s).
ASK
When conducting an evidence-based practice project,
a clear and precise articulation of the question is critical.
The question should be asked in a format that will yield the
most relevant and best evidence. Evidence-based practice
questions sound like research questions, but stop short of
producing a research project. Thus, there is no research design,
data collection or analysis of data from subjects. Instead, the
project uses secondary data, which already exists in the literature
of previously conducted studies.
The PICO format is an excellent way to formulate evidence-
based practice questions. An example will help illustrate:
“Do nursing educational interventions decrease
adult smoking behaviors more than other educational
quit-smoking programs?”
The PICO format is outlined, based on the above example:
Patient
atient Population – Specifically defined, what group of patients
will be studied? In the example, adult smokers are the population.
Intervention
ntervention – What event will be studied? In the example, this is
educational interventions by nursing staff.
Comparison – To what will the intervention be compared?
Is it better or worse than no intervention at all or than another
intervention? In the example, other educational quit-smoking
programs such as classes or counseling will be compared to
the nursing education intervention.
Outcomes – What is the effect of the intervention? In this example,
the PICO question is formulated by asking how the outcomes
data of each stop-smoking intervention approach compare to
one another.
continued on page 4
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Principles of Evidence-Based Practice for Case Managers (continued from page 3)
GATHER
The focused question is now used as the basis for a literature search
to identify the most credible and relevant evidence from research. The
first step in a literature search is to identify background questions about
the current standard of practices, the disease, treatment and specific
population characteristics. These questions, which are complementary
to the PICO-formatted research question, can be answered by
background sources used to enhance knowledge on the topic.
Once a practitioner is knowledgeable on the topic, a systematic
review of current literature is conducted, including:
• Practice guidelines
• Meta-analysis/Meta-synthesis (methods of combining the
results of independent research studies)
• Research reports
• Systemic/Integrative reviews
• Current practices
• Prognosis/Harm information
• Economic evaluations
• Quality-of-care indicators
Convenient sources for background information include
UpToDate (www.UpToDate.com) and the American College of
Physicians (ACP) Physicians’ Information and Education Resource
PIER (www.pier.acponline.org).
Searching effectively and efficiently requires a targeted
approach, and there are a variety of tools and strategies available to
facilitate the process. Research on a topic may be listed under
multiple key words. To account for this, MeSH is a controlled
vocabulary developed by the U.S. National Library of Medicine and
is used for indexing articles for MEDLINE/PubMed. It provides a
consistent way to find information that may use different
terminology for the same concepts.2 It may also be effective to use
multiple keywords, keyword combinations and synonyms.
Applying limits by population or study design can help limit
a search and avoid an overwhelming amount of search results.
For filtered or pre-processed information and best evidence to
date, several resources have been synthesized and evaluated:
• Cochrane Library-Database of Systemic Reviews
• National Guidelines Clearinghouse (AHRQ)
• ACP PIER
Original studies offering unfiltered information are also available,
though they must be evaluated for validity regarding the researcher’s
specific research question. (See the following section on Assessment
and Appraisal). Sources for original research studies include:
• MEDLINE,
• CINAHL (Cumulative Index to Nursing and Allied Health
Literature, www.cinahl.com),
• SCOPUS (www.scopus.com) and,
• BIOSIS (www.biosis.org)
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C A S E M A N A G E M E N T
ASSESSMENT AND APPRAISAL
Assessing and appraising the relevancy of research studies is
critical to a skilled evidence-based practice. This step focuses on
evaluating the relevancy of each study to the question at hand,
and assessing the quality and validity of the studies. Relevancy is
usually more easily assessed than quality and validity, and assessing
validity of a study is a judgment. The judgment, however, should be
guided by the following basic principles:
• Does the study actually measure, objectively, what it
sets out to measure?
• Is the purpose of the research well-defined, and are common
concepts used to design objective data collection?
• Do the study’s design, implementation and analysis
minimize bias?
• Are there a number of studies that have evaluated the
research question, including sample size across the studies?
• Are conclusions well-justified by the data?
• Is the study replicable?
• Is there consistency among studies that have similar and
different designs yet have the same research questions and
similar findings?
There are a variety of available tools or models for critiquing
research studies. While this article is not intended to describe or
endorse a particular model, each can play a role in the evaluation
done by an evidence-based practice researcher. One set of tools that is
commonly used to evaluate research studies is the Critical Appraisal
Skills Program (CASP) instruments. These tools are used to evaluate
specific types of study designs, such as randomized controlled trials,
qualitative studies, cohort studies and case-control studies.
If the goal is to evaluate a clinical guideline, the Appraisal of
Guidelines for Research Evaluation (AGREE) tool assesses the quality
of clinical practice guidelines that a researcher may be considering.3
This tool has 25 questions that assess the quality of a guideline.
There are also a variety of evidence grading systems that
evaluate the study design as well as the strength of the study and
the consistency and number of studies with the same findings.
One system uses seven levels to categorize the strength of evidence
as assessed by the researcher.3
Level I – a meta-analysis or systematic review of multiple
randomized controlled trials (RCTs) and experimental studies.
Level II – evidence from at least one well-developed RCT or
experimental study.
Level III – evidence from a well-developed quasi-experimental study.
Level IV – evidence from non-experimental studies.
Level V – evidence from systematic reviews of descriptive and
qualitative studies.
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Level VI – evidence from a single descriptive case report, or
qualitative research.
Level VII – opinion of respected authorities – nationally known.
Additional considerations, though not litmus tests for validity,
might include whether the article publishing the study is peer-
reviewed, the reputation of the journal or publication in which the
study is published, and, whether the study fits into the context of
literature and previous research on the subject.
After evaluating the design and validity of a study, the researcher
must also consider the level of evidence the study design provides.
Specifically, whether the results demonstrate that an intervention or
treatment actually improves patient or staff outcomes relative to the
practice in question. The results should be clinically meaningful – the
difference made by the treatment or intervention must be of sufficient
magnitude. Finally, the results must be applicable to the specific
patient for whom this evidence-based practice is being developed.
ACT
Ultimately, the purpose of the assessment and appraisal step is
to determine whether the research base is sufficient to influence
clinical practice. Considerations – in addition to the strength of
evidence and the consistency of findings across the studies
evaluated – must also include the feasibility for practice and the risk/
benefit ratio. The risk/benefit ratio takes into consideration whether
the research evidence validates current practice, suggests a minor
practice change or a major practice change – how risky to the patient
is the intervention in the context of the confidence the clinician
holds in the research evidence? Again, this falls to the judgment of
the researcher and/or clinician.
If the evidence does not clearly support a change in practice, the
clinician should continue to evaluate the quality of care and any new
knowledge on the research question, stepping through this process
again as new evidence surfaces.
If the evidence evaluated is sufficient to influence clinical
practice, the next step is to design and systematically implement an
intervention to current practice. Implementation must include
monitoring and an analysis of the outcome.
Implementing a new practice intervention also requires clear
and open communication with the care team. All team members
must see that practice is based on evidence, and the evidence must
be shared openly and thoroughly. These stakeholders must also
review the new process or practice and provide feedback. If a new
practice is to be implemented broadly throughout a department or
unit, it is useful to hold focus groups with stakeholders in advance of
implementation to provide a forum for discussion of questions,
concerns, and potential areas of resistance.
EVALUATE
Evaluating outcomes data is a step that is often comfortable for
case managers and other clinicians, and it is a critical step in the
process of evidence-based practice. The specific, relevant outcome
of interest must be identified. For example, if a new intervention in
the practice of caring for patients with catheters is implemented, the
outcome of interest may be the incidence of acquired infections.
The important steps to outcomes data evaluation are:
• Determine the methods and frequency of data collection.
• Determine the baseline and follow-up samples.
• Design the data collection form.
• Provide feedback to staff members regarding the
progress in achieving change.
• Facilitate the feedback of analyzed data to the staff.
• Use the outcomes data to assist staff members in
integrating the evidence-based practice.
CONCLUSION
Many of the skills outlined here that contribute to successful
evidence-based practice are familiar skills to case managers. Perhaps
the most significant barrier in some practice settings is a lack of
understanding the resources that are available and what tools may
be employed. While knowledge of statistics can be an asset, it is
certainly not required. If implementation of new practice requires an
in-depth understanding of clinical findings that include statistical
data, case managers may also engage a statistician or a medical
research department to assist in understanding and developing the
intervention plan.
By increasing use of an evidence-based practice approach to the
practice of case management, case managers will be participating in
the continual improvement of patient care – both clinical quality of
care and the care experience.
Geri Wood, PhD, RN, FAAN, has been the Director of Nursing
Research and Evidence-Based Practice at UT M. D. Anderson Cancer
Center in Houston, TX for one year. She has also been an Associate
Professor at the University of Texas Health Science Center School of
Nursing in Houston, TX for the past 17 years. She earned her doctorate
from New York University in New York, NY, and earned her bachelor
and masters degrees from the University of Rochester in Rochester, NY.
During her career she has also served as Department Chair and
Associate Professor for the College of Nursing at the University of
Nebraska in Omaha, NE. Dr. Wood is the principal editor and author
of the textbook, Nursing Research: Methods and Critical Appraisal for
Evidence-Based Practice, which is currently in its sixth edition.
ENDNOTES
1 Sackett, D.L. et al. (1996). “Evidence Based Medicine: What It Is and
What It Isn’t.” BMJ 312 (7023), 13 January, (71-72).
2 A tutorial can be found at http://www.ncbi.nlm.nih.gov/sites/.
3 LoBiondo-Wood, G & Haber, J.(2006). Nursing Research: Methods and
Critical Appraisal for Evidence-Based Practice. 6th Edition, St Louis,
Mosby, Elsevier.