Evidence-based practice (EBP) is firmly entrenched in the lexicon of physical therapist practice,1,2 but beliefs about how best to translate scientific evidence into clinical practice are far from settled. There are major gaps in our scientific knowledge; however, even more disturbing is the fact that an enormous amount of existing scientific knowledge remains unused in practice. As noted in the Institute of Medicine (IOM) report titled Crossing the Quality Chasm, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”3
Thankfully, the infamous 264-year period between the discovery of citrus’s benefit in preventing scurvy and the widespread use of citrus on British ships is no longer the norm.4 But the frequently quoted statement about the lag time between publication and adoption of research—only 14% of original research is applied for the benefit of patient care, and that takes 17 years5,6—is alarming enough. There is consensus that the transfer of evidence from proven health care discoveries to patient care is unpredictable and highly variable and needs to be accelerated.4,7,8
For those of us who want to speed the adoption of EBP in physical therapy and across health care more broadly, Naylor9 described 4 distinct phases or strategies that are instructive:
Phase 1, the “Era of Optimism,” is characterized by a belief in passive diffusion of scientific evidence into practice. In this (still-dominant) phase, students and clinicians are trained to critically appraise the scientific literature to identify valid new information that could be applied to practice.
Phase 2, the “Era of Innocence Lost and Regained,” acknowledges that much of clinical practice is not evidence based and that it is virtually impossible for clinicians to keep up with the explosion of medical literature. This understanding has led to the emergence of evidence-based clinical practice guidelines, in which the literature is systematically reviewed and summary recommendations are graded according to the strength of the supporting evidence. Guidelines are widely disseminated on the assumption that providers will read them and that practice will change accordingly.
Phase 3, the “Era of Industrialization,” is on the rise, as evidence mounts that the passive efforts of phases 1 and 2 fail to actually change practice. In this phase, aggressive strategies are implemented by regulatory entities or professions to improve care. These efforts frequently involve performance measurement and reporting,10 which are intended to encourage providers to become more accountable and more focused on quality improvement. Many professions have risen to this challenge and have developed their own approaches to change patient management as described by Naylor.9APTA’s Physical Therapy Outcomes Registry,11 an organized system for collecting data to evaluate patient function and other clinically relevant measures, is a phase 3 effort, with improving practice and fulfilling quality reporting requirements as 2 of its major goals.
Phase 4, the final phase, is the “Era of Information Technology and Systems Engineering,” which is driven by the belief that it is not sufficient to focus on individual practitioners, but rather the redesign of service delivery systems to address barriers and incentives is required to bridge the wide gap between best evidence and common practice. For this phase, a different type of evidence base—one describing the most effective ways to change provider behavior9,12—is needed. Hence the emergence of the relatively new field of implementation research.
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