Evidence-based practice in healthcare: Is it on shaky ground?

“Federal panel recommends against prostate cancer screening.” This news headline may have given some nurses a sense of déjà vu, and not for the best reasons.

The recommendation on prostate cancer screening was made by the United States Preventive Services Taskforce (USPSTF), a federal advisory panel that makes recommendations on health and medical disease prevention interventions. The USPSTF reviews available evidence on a particular intervention, in this case the prostate cancer antigen blood test (PSA), to determine if how effective it is at preventing the disease or condition. It then assigns the recommendation a “grade” of A through D, with A being the highest, similar to school grades.

On Oct. 7, the USPSTF released the draft recommendation statement on screening for prostate cancer for public comment. The recommendation, based on the review of the evidence of incidence of and mortality from prostate cancer after PSA testing, was that the screening test was actually more harmful than beneficial. PSA tests were found to have significant number of false-positive results, and men with those results had unnecessary invasive biopsies, which often led to issues such as bleeding, infection, and pain. The USPSTF assigned PSA-based screening for prostate cancer a grade of “D” – meaning that harms of the intervention outweigh the benefits so greatly, that the use of the service should be discouraged.

But the headlines in the news brought images of another cancer-related recommendation that met with outrage and bitter objection from many in the patient and cancer outreach communities. In October 2009, the USPSTF issued a recommendation against certain breast cancer detection interventions, including mammograms, for certain populations of women. That recommendation drew fire from breast cancer survivors, advocacy groups, and politicians. The timing was unfortunate – October is national breast cancer awareness month, and the U.S. Congress was at the time in the midst of the roiling health care reform debate.

While this recent draft recommendation — which is open to public comment until Nov. 8 — might be less controversial, it raises the question of whether the public and even providers are truly ready for evidence-based practice. Considering the weight of importance placed on prevention by the Affordable Care Act (ACA) and the intense pressure to find the most effective treatments to curb health costs, the public reaction to USPSTF recommendations could influence the future of the concept.

The potential for pushback

Many healthcare professionals understand the notion of evidence-based practice. It is similar to a lawyer introducing evidence to prove a case in court. In evidence-based healthcare, medical research, outcomes data, and certain subjective factors must prove an intervention “works” for providers to defend its use in practice. It makes sense — do what works, and don’t do what doesn’t. However, this may be easier said than done.

The 2009 breast cancer recommendation tempest highlighted the threats to evidence-based practice. Preventive services can often take a long time to gain traction, requiring long-standing, consistent recommendations. Motivated advocacy groups aimed at preventing certain diseases push preventive measures, such as cancer screening, to become mainstream. So a sudden about-face on those measures can be met with severe backlash — even if the reason for the about-face is an honest review of the evidence that these things are not working, or are even harmful.

Yet, ready or not, the use of evidence-based practice, and a related concept called “comparative effectiveness research,” will become integrated into healthcare in the U.S. as part of the ACA. It is seen as a way of reducing costs while improving outcomes, since acceptable (and reimbursable) practices must demonstrate effectiveness through evidence. The ACA allocated significant funding for comparative effectiveness research — a take on evidence-based practice that compares medical interventions or systems with one another to determine which works best. As part of the preventive services regulations emulating from the ACA, all USPSTF grade “A” and “B” recommendations must be covered by public and private insurers at no cost to the patient. Other federal advisory panels, such as the Advisory Committee on Immunization Practices, are suddenly seeing their recommendations take on tremendous new clout due to similar inclusion in the ACA.

Helping evidence-based practice succeed

Nurses can be instrumental to the success of evidence-based practice. Nursing practices should integrate an analysis of evidence, and encourage changes in practice if the evidence deems it necessary. Nurses should also advocate for the inclusion of values and subjective data of the public or even individual patient. This is crucial to ensuring the simultaneous use of patient-centered care and evidence-based practice. Making decisions based on static research can be meaningless if the patient’s preferences are not considered to be just as important.

Change can be difficult, but it seems that change in healthcare is even moreso. The trend towards evidence-based practice will continue as a necessary change for healthcare to be transformed in this country. Nurses, as trusted and reliable sources of information for patients and the public, are key to ensuring that it can succeed.

 

Katie Brewer is a senior policy analyst at ANA.

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2 thoughts on “Evidence-based practice in healthcare: Is it on shaky ground?”

  1. Susan M. Jussaume, NP says:

    Thank you for this timely thought-filled article. I will be sure to use it as part of my forum in seminar class for discussion with my graduate NP students.

  2. Anonymous says:

    Staff Nurses need more education about their role in the evidence-base practice process

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