In this chapter, the background to the development of the book is outlined as are some of the reasons why we felt it was timely and appropriate to bring together a text which focuses on the outcomes of implementation of evidence-based practice (EBP). Experts in the field of knowledge translation and EBP invited to contribute chapters to the book were asked to consider how to determine if outcomes of EBP in their areas of expertise were efficacious, how efficacy could be measured, and how to ascertain if the outcomes of interest were the most important from the perspectives of relevant stakeholders. As described by Ian Graham and colleagues in Chapter 2, outcomes of EBP could include change in behavior demonstrating use of evidence in practice and impact of use on outcomes such as better health and more effective use of healthcare resources.

We hope that by reading the chapters and following the perspectives presented by the authors that the need to accord equal priority to the outcomes of implementation as with all other steps to support the use of research in practice will become apparent. Most of us live in countries where healthcare resources are finite, an issue whether our healthcare is largely funded through our taxes or private insurance schemes. Some readers will reside in countries where healthcare systems face an unprecedented increase in the burden of ill health arising from chronic, non-communicable diseases—for example as a consequence of the epidemic of obesity or an aging population. Others will reside in countries which face epidemics of disease including TB, HIV/AIDS, persistent high maternal and infant mortality and morbidity, or where poor or fractured infrastructure cannot support an effective healthcare system. For those living in developed countries, while there have been unprecedented advances in healthcare technology and year on year increases in healthcare funding from government, the increase in resources has not been matched by improvements in health. This is most evident in the US, where it is estimated that healthcare costs for 2009 were $2.7 trillion, the highest level of healthcare spend anywhere in the world, yet life expectancy is lower than in many other developed and middle-income countries indicating large discrepancies between healthcare costs and outcomes (Institute of Medicine 2009). We also have healthcare systems where despite a plethora of technology, gaps remain in the quality of data to accurately inform and compare the outcomes of care. In the UK, efforts to gauge whether investment in healthcare following the election of a Labour government in 1997 had resulted in improved health outcomes were hampered by constraints in measures of quality and need for better measures of output and outcome extending beyond hospital episode data (Lakhani et al. 2005).

For the last two decades, in response to some of the reasons outlined above, greater emphasis has been placed on the need to provide healthcare informed by evidence of effectiveness, the premise being that use of evidence will optimize health outcomes for the service user and maximize use of finite healthcare resources. The main drivers for EBP have come from political and policy initiatives which also instigated the establishment of organizations to develop guidance to inform healthcare such as the National Institute for Health and Clinical Effectiveness (NICE) in England and Wales, the Scottish Intercollegiate Guideline Network, and the US Agency for Healthcare Research and Quality. The remit of a national body such as NICE is to make recommendations for care based on best evidence of clinical and cost-effectiveness. Suites of guidelines to inform a range of acute and chronic physical and psychological health conditions and appraisals of innovations in technology and pharmacology have been developed and published by NICE which aim to standardize patient care, reduce variation in health outcomes, discourage use of interventions with no proven efficacy, and encourage systematic assessment of patient outcomes. The National Institute for Health Research which funds research to inform National Health Service (NHS) care in England requires studies funded across all of its programs to provide evidence of clinical and cost-effectiveness.

The role of NICE in the synthesis and dissemination of evidence to prioritize healthcare interventions has generated criticism that it promotes rationing in healthcare (Maynard et al. 2004), an issue with implications for determining how outcome measures are derived to elicit benefit and from whose perspective. As Maynard and colleagues (2004) write “…rationing is the inevitable corollary of prioritization, and NICE must fully inform rationing in the NHS,” the issue being not whether but how to ration (p. 227). In the UK, publication of NICE guidance which does not support the use of a particular drug or therapy because the evidence reviewed did not indicate clinical or cost-effectiveness has frequently been challenged by industry (Maynard & Bloor 2009), service user charities, and in media reports of an individual’s experience of being refused treatment which did not comply with NICE recommendations. Recent NICE recommendations which generated criticism about its role include restrictions on use of the drugs for people with early stage Alzheimer’s disease, restrictions to fertility treatments, and use of drugs to treat kidney cancer. In some instances, the Department of Health was forced to reverse the original NICE recommendation to deflect public criticism, for example the use of Herceptin for women with early stage breast cancer (Lancet 2005). Nevertheless, this is an interesting juxtaposition—whose outcomes should receive the highest priority when decisions about healthcare interventions and optimal use of finite resources are made? That certain treatments may make a difference to someone’s quality of life will not influence recommendation for use across the NHS if the evidence assessed does not demonstrate clinical or cost-effectiveness at thresholds set by NICE. The recent introduction of “top up” fees to enable patients to bypass NICE recommendations and purchase drugs not recommended for NHS use reflects the power of today’s informed healthcare consumer (Gubb 2008). Although only likely to be utilized by a small group of people, as Maynard and Bloor (2009) propose, this raises issues about the role of NICE and regulation of the pharmaceutical industry; how drug prices should be determined; and how, if at all, to deal differently with rare or end-of-life conditions when making resource allocation decisions in healthcare. It also introduces the issue of consumers opting to purchase interventions which they view as likely to provide a better outcome which could include aspects of physical and/or psychological health and/or well-being.

The development of strategies to encourage use of evidence to inform decisions about healthcare was stimulated initially by what has been referred to as a “movement” for evidence-based medicine (EBM). One of the first people to propose that medical care should be informed by evidence of effectiveness was Archie Cochrane, whose book Effectiveness and Efficiency: Random Reflections on Health Services was published in 1972. Cochrane also advocated that this approach should be applied to education, social work, criminology, and social policy (Cochrane 1972). The work of Archie Cochrane triggered groups such as those led by Gordon Guyatt and David Sackett to develop methods to synthesize and critique evidence to support decisions in clinical practice. In the late 1970s and 1980s, Ian Chalmers at the National Perinatal Epidemiology Unit in Oxford pioneered the methodology to systematically review the evidence related to effective care in pregnancy and childbirth. Building on this work, the Cochrane Centre was established in 1992 and was crucial for the spread of EBM, which in turn stimulated revisions to healthcare education and training, policy development, publication of new journals, and establishment of academic centers. Principles of EBM have subsequently been applied to support the commissioning of healthcare services, recommendations for pharmacology treatments, surgical interventions, diagnostic tests, and medical devices. Of note is that although attention has been paid to the use of measures of “outcome,” limited attention has been paid to the definition or consequences of a “good” or “poor” outcome. Reviewers for the Cochrane Pregnancy and Childbirth group define an outcome as an “adverse health event” (Hofmeyr et al. 2008). In a Cochrane review, data from meta-analyses of relevant trials will be presented in a forest plot with the beneficial effect of an intervention presented to the left of the “no effect” line and a harmful effect to the right of the line. This is an extremely useful way to present outcomes of pooled data, but it is one part of the picture if we are to ensure that outcomes are the most relevant for all concerned. Further exploration of outcomes is required in order that consequences beyond implementation can be considered from a range of perspectives, an important stage in the continuum of research use.

There is ongoing debate as to the definition of “evidence” and what counts as evidence, although it seems consensus has been reached that evidence can come from a number of sources and not just the findings of randomized controlled trials (RCTs). A recent position paper from Sigma Theta Tau describes research evidence as:

methodologically sound, clinically relevant research about the effectiveness and safety of interventions, the accuracy and precision of assessment measures, the power of prognostic markers, the strength of causal relationships, the cost-effectiveness of nursing interventions, and the meaning of illness or patient experiences.

(Sigma Theta Tau International 2005–2007, Research and Scholarship Advisory Committee Position Statement 2008, p. 57)

In a 1996 commentary in the British Medical Journal, Sackett et al. (1996) defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,” and stressed the need for the clinician to use evidence along with their expertise and judgment to make decisions which also reflected the choice of the individual patient. A later British Medical Journal commentary reiterated that evidence alone should not be the main driver to change practice and that preferences and values needed to be explicit in clinical decision making (Guyatt et al. 2004). Of note is that the authors highlighted that the biggest future challenge for EBM was knowledge translation (Guyatt et al. 2004). The need to synthesize evidence for use by busy clinicians, to place evidence in a “hierarchy” with the most robust evidence at the top of the hierarchy and acknowledgment that evidence can come from a number of external sources continues to be emphasized (Bellomo and Bagshaw 2006).

When reading any literature which refers to use of evidence, it is apparent that a number of terms have been used to describe the process which include EBM, EBP, evidence-based clinical decision making and evidence-informed practice. The term evidence-based practice is more commonly used to describe evidence use by nurses, midwives, and members of the allied health professions (Sigma Theta Tau International Position Statement 2008).

Throughout this book, we refer to EBP in line with the following definition:

the process of shared decision making between practitioner, patient, and others significant to them based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how, and other available robust sources of information.

(Rycroft-Malone et al. 2004)