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Crossing the Quality Chasm: A New Health System for the 21st Century
Development of decision support tools to assist clinicians and patients in applying the evidence
Identification of best practices in the design of care processes
Development of quality measures for priority conditions
It is critical that leadership from the private sector, both professional and other health care leaders and consumer representatives, be involved in all aspects of this effort to ensure its applicability and acceptability to clinicians and patients.
Early definitions of evidence-based medicine or practice emphasized the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al., 1996). In response to concerns that this definition failed to recognize the importance of other factors in making clinical decisions, more recent definitions explicitly incorporate clinical expertise and patient values into the decision-making process (Lohr et al., 1998). Contemporary definitions also clarify that “evidence” is intended to refer not only to randomized controlled trials, the “gold standard,” but also to other types of systematically acquired information.
For purposes of this report, the following definition of evidence-based practice, adapted from Sackett et al. (2000), is used:
Evidence-based practice is the integration of best research evidence with clinical expertise and patient values. Best research evidence refers to clinically relevant research, often from the basic health and medical sciences, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination); the power of prognostic markers; and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. Clinical expertise means the ability to use clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, individual risks and benefits of potential interventions, and personal values and expectations. Patient values refers to the unique preferences, concerns, and expectations that each patient brings to a clinical encounter and that must be integrated into clinical decisions if they are to serve the patient.
Evidence-based practice is not a new concept. One of its earliest proponents was Archie Cochrane, a British epidemiologist who wrote extensively in the 1950s and 1960s about the importance of conducting randomized controlled trials to upgrade the quality of medical evidence (Mechanic, 1998).
Evidence has always contributed to clinical decision making, but the standards for evidence have become more stringent, and the tools for its assembly and analysis have become more powerful and widely available (Davidoff, 1999). Prior to 1950, clinical evidence consisted of case reports, whereas during the latter half of the 20th century, results of about 131,000 randomized controlled