Evidence Based Medicine

Knowledge, Perceptions, Attitude and Educational Needs of Physicians Towards Evidence Based Medicine

ABSTRACT

Objectives: To define the knowledge, perception, attitude and educational needs of the towards evidence based medicine and to explore perceived barriers to practicing evidence based medicine among physicians in Governmental hospitals and primary health care centers, Ministry of Health in Abha city, Kingdom of Saudi Arabia.

Method: Cross-sectional study using self administered validated questionnaire distributed to 290 (resident, specialist and consultant) during July 2008.

Results: Completed questionnaires were received from 210 of 290 physicians (72.4%). The physicians in general had positive attitude towards EBM (Median score=8/10), and half of them support the shift from individual to evidence based practicing. The respondents showed acceptable level of knowledge about the terminologies used in EBM and critical appraisal namely; epidemiological and statistical terms and definitions and it was found that the trained physicians had better knowledge if compared to their untrained counterparts, and also, the specialists and consultants had better knowledge about EBM when compared with residents. The main barriers facing the respondents in practicing EBM as indicated by the physicians were lack of resources and time.

Conclusion: Although the physicians showed acceptable level of knowledge about EBM, nevertheless there was a gap between their knowledge and practice, and this gap could be attributed to what was addressed by the physicians that there were barriers facing their practice of EBM namely, inadequacy of time and unavailability of access to internet in their working place. The relatively better knowledge of the trained than the untrained physicians could draw the attention towards the importance of training courses pertinent to EBM.

المستوى المعرفي والسلوكي والإدراكي للأطباء وحاجتهم التعليمية

للطب المبني على الأدلة

مدينه آبها, المملكة العربية السعودية, 2008

د/حسن محمد الموسى

جامعه الملك خالد, كلية الطب

قسم طب الأسرة والمجتمع

الملخص

الأهداف: معرفة المستوى المعرفي والإدراكي والسلوكي والحاجة التعليمية لأطباء مدينة أبها نحو الطب المبني على الأدلة و لاكتشاف المعوقات التي تحول دون ممارسة الطب المبني علي الأدلة. المستشفيات الحكومية ومراكز الرعاية الصحية, مدينة أبها, المملكة العربية السعودية.

الطريقة: الدراسة تمت بالشكل المقطعي باستخدام استبيان تم توزيعه ذاتيا على 290 طبيبا

من (المقيمين, الأخصائيين والاستشاريين ) في شهر يوليو لعام 2008.

النتائج: بناء على الاستبيانات المكتملة استجاب 210 من 290 بنسبة (72.4%). وبصفة عامه فإن الأطباء لديهم موقف ايجابي نحو الطب المبني على الأدلة (متوسط التسجيل =8/10), ونصفهم أيد الانتقال من الفردية إلي الطب المبني على الأدلة. ولقد بينت الإجابات المستوى المعرفي المقبول عن علم المصطلحات في الطب المبني على الأدلة و التقييم الشامل للأوراق العلمية والمسمى: الوبائية والتعبيرات الإحصائية والتعريفات, ولقد وجد أن الأطباء المدربين لديهم معرفة أفضل إذا ما قورنت بالأطراف الغير مدربة وأيضا المتخصصين والاستشاريون لديهم من المعلومات الأفضل عن الطب المبني على الأدلة عند مقارنتهم بالأطباء المقيمين. المعوقات الأساسية في ممارسة الطب المبني على الأدلة كما تم توضيحها من قبل الأطباء كانت في عدم توافر الوقت والمصادر.

الخاتمة : برغم أن الأطباء قد بينوا مستوى معقول من المعرفة عن الطب المبني على الأدلة ومع ذلك فانه كان يوجد فجوة بين معرفتهم وبين ممارستهم وهذه الفجوة يمكن أن تعود إلى ما إذا كانت مواجهه من قبل الأطباء حيث كانت توجد معوقات تواجه ممارستهم الطب المبني على الادلة نذكر منها : القصور في الوقت وتعذر الوصول إلي الانترنت في أماكن عملهم . إن المعرفة الأفضل نسبيا للأطباء المدربين عن الغير المدربين يمكن أن توجه الانتباه إلي الدورات التدريبية ذات الصلة بالطب المبني على الأدلة وفائدتها.

Introduction:

Evidence based medicine is a strategy to solve problems, to learn effectively and efficiently, to remain up to date , to empower learners and decision maker , to avoid wasteful expenditure and to improve quality of health care. (1) Historically, the evidence based medicine first appeared in 1970 in the information brochure for McMaster university internal medicine residency programmed. However, the work which led to its origin may be traced back to late 1970s. (2)

EBM has one main goal: to improve the health of people through decision that will maximize their health related quality of life and life span. The decision may be related to public health, health care, clinical care, nursing care or health policy. (3)

The approach of EBM summates the integration between three fundamental issues: (4)

1. Best research evidence;

It is clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic test, the power of prognostic markers, efficacy and safety of therapeutic, rehabilitative and preventive measures.

2. Clinical expertise

It is the ability to use clinical skills and past experience to rapidly identify each patient unique health state and diagnosis, their individual risk and benefits of potential intervention, and their personal values and expectation.

3. Patient values

It is the unique preference, concern and expectation each patient brings to a clinical encounter and which must be integrated into clinical decision if they are to serve the patient.

The rapid spread of Evidence Based Medicine has arisen from four realizations encountered in clinical practice: (4) 1. Our daily need for valid information. 2. The inadequacy of traditional sources for this information. 3. The disparity between our diagnostic skills and clinical judgments. 4. Our inability to afford more than a few second per patient for finding and assimilating this evidence.

The practice of Evidence Based Medicine can be divided into the following components; (5)

* Identify a problem or area of uncertainty

* Asking a relevant, focused, clinically important question that is answerable.

* Selecting the most likely resources to search

* Searching and appraising the evidence found

* Assessing the clinical importance of the evidence

* Assessing the clinical applicability

* Acting on and appropriately of the evidence

* Assessing the outcome of the actions

* Authoring-summarizing and storing record for future reference

Evidence Based Medicine has established its place as important contributor to the methodological toolbox for health services research. (6) As it was proven that patient who receives evidence based medicine therapies has better outcomes than those who don't. (7)

From policy making view, EBM would be seen as one organ in relation to many others making their contribution to the body knowledge needed for clinical decision. (6)

There are three limitations that are unique to the practice of evidence based medicine: (7) First, the need to develop new skills in searching and critical appraisal can be daunting; Second, busy clinician have limited time to master and apply these new skills, and the third limitation is referred to the inadequate resources required for instant access to evidence.

The main challenge in practicing EBM as identified by a study conducted in USA was the gap between what is known and what is done, in addition to the need sometimes for instant sources of EBM, and in an attempt to fill this gap and overcome the difficulty in accessibility to information an intervention study which established a bedside sources of simplified updated information to help health care providers in decision, the post-intervention assessment results were encouraging to disseminate the approach. (8)

In a study conducted in Riyadh, KSA to assess attitude and performance of physicians towards EBM, it was found that there were barriers facing them in practicing EBM. (9) The same findings were also observed in another study included consultant physicians working in governmental health institutes in Al Taif city where it was ascertained that there were still many barriers from perspectives of the physicians regarding the practicing of EBM. (10)

In a study conducted in Dammam city, KSA, for assessment of primary health care centers (PHCCs) and general hospitals physicians' attitudes towards evidence-based medicine (EBM), it was elicited that there was an overall positive attitude among physicians towards EBM, and there was a proportional relation between the knowledge of EBM and attitude towards it. (11)

Methods :

Study was Cross-sectional study in which a questionnaire adopted from McColl et al who used the same questionnaire for the same study purpose in south England, (12) in addition to the modifications followed by Dr Lubna A Al-Ansary and Tawfik A Khoja In their study which was carried out for primary care physicians practicing at the Ministry of Health Primary Health Care Centers in Riyadh region, Saudi Arabia October 1999. (9)

The questionnaire recorded the demographic data such as age, gender, nationality, specialty, name of Graduation University, number of years of practice and previous EBM Education. Main outcome measures were respondents' knowledge, attitude towards evidence based medicine, ability to access and interpret evidence and perceived barriers to practicing evidence based medicine.

Questionnaire distributed to all governmental physicians working in Abha city presented at the time (July 2008) of data collection were considered eligible to be included in the study. It was estimated that the number of physicians working in the governmental hospitals and primary health care centers in Abha region to account for 350 physicians. Out of them there were 290 physicians available at the time of the study and they were all invited to be enrolled in the study, the respondents accounted for 210 physicians making a response rate of (72.4%). Data were entered in a personal computer by the researcher and were analyzed by SPSS version 14. For descriptive analysis of the characteristics of the study group the frequency distribution was used, and for the scores reflecting attitude and knowledge of the physicians the Median central tendency was used provided that these observations are ordinal in nature, thereby, and for comparison of the knowledge and attitude according to the different sub groups Mann Whitney and Kruskal Wallis were used. For the categorical variables the Chi Square test was performed. P value less than 0.05 was considered as an indication to significant difference throughout the study

Ten physicians were selected as a Pilot study and Ethical consideration written permission from the authority to conduct the research (appendix), Consent was considered as a prerequisite for enrollment in the study, Questionnaires were given to the physicians with personalized cover letter and all the collected data were kept confidentially and not disclosed except for the study purpose.

Results:

More than half of the physicians enrolled in the study (58.6%) aged less than 40 years, and the majority were males (85.7%). Almost equal percentages of consultants, specialists and residents from each subspecialty (surgery, medicine and PHC) were presented in the study. It was remarked that half of the physicians (50%) had postgraduate board certificates. The physicians who had formal training in search strategy accounted for 15.7%, in addition to 18.1% who stated that they had previous formal training in critical appraisal.

The overall score reflecting attitude of the physicians accounted for 8/10. It was noted that there is a significantly consistent increase in the attitude of the physicians towards EBM as they are getting older, the median score ranged between 7/10 for those aged less than 30 years and 9.5/10 for older physicians (50+ years) p<0.05. No statistically significant difference was found among the respondents according to their gender, job title nor postgraduate qualifications. (Table 1)

Also, It was evident that the perceived importance of practicing EBM on patients' care increases significantly towards older age, the median score ranged between "7/10" for the physicians aged <30 years to "9/10" among physicians in the age group 40+ years p<0.05. Meanwhile, it was noted that the PHC consultants pointed out to the higher scores (9.5/10) followed by the surgery and medical consultants (9/10), while the lowest score was recorded among medical specialists (Median score= 7.5) and this difference is statistically significant p<0.05. However, neither gender nor postgraduate certification had significant impact on perception of the physicians about the importance of EBM on patients' care.

Seeking and applying evidence based summaries, which give the clinical "bottom line" was chosen by significantly higher percentage of the physicians working in the medical departments (68.6%) than those working in PHC (40.8%) and surgery departments (40.6%) p<0.05. Meanwhile, it was noted that using evidence based practice guidelines or protocols developed by colleagues was chosen by significantly higher percentage of the physicians working in PHC (63.4%) than those working in the surgery (49.3%) and medical departments p<0.05. (Table 2)

The man barrier considered by the physicians was the lack of distributed updated clinical letters, journals and guidelines (51%) which was followed by absence of internet access (50%). The least considered barriers were the expenses (19%) and consumption of time (17.6%). More than one third of the physicians (37.6%) indicated that one of the main barriers was the non availability of time, and the percentage among residents (44.2%) was significantly higher than the specialists (36.7%) and consultants (13.3%) p<0.05. Meanwhile, it was noticed that the majority of the consultants (73.3%) indicated that the absence of distributed updated clinical letters, journals or guidelines was a main barrier for conducting EBM compared to 55% of the specialists and 43.3% of the residents and this difference is statistically significant p<0.05. (Figure 1)

The total percentage of physicians who reported that they either understand only or they understand and could explain EBM to others was significantly higher among physicians who had formal training in research strategy if compared to those who didn't p<0.05. It accounted for (78.1% Vis 62.5% for "relative risk"), (90.6% Vis 67.1% for "absolute risk"), (78.1% Vis 64.7% for "systematic review"), (83.9% Vis 49.1% for "odds ratio"), (77.5% Vis 55.1% for "meta analysis"), (67.4% Vis 60.8% for "clinical effectiveness"), (74.2% Vis 55% for "Number Needed to Treat", (64.5% Vis 49.7% for "confidence interval"), (67.7% Vis 47.9% for "heterogeneity") and (67.8% Vis 47.9% for "publication bias").

Discussion:

The current study showed that the physicians in general had positive attitude towards EBM which come in accordance to the findings of a study conducted in other settings worldwide e.g. in Poland, (13), Iran (14) and Malaysia (15). In addition to the positive attitude towards EBM, our study showed that almost half of the studied physicians supported the claim of necessity to shift from individual based to evidence based decision, this notion was ascertained in a study conducted in USA. (16) These findings are of utmost importance for future planning of training and disseminating the practice of EBM to our physicians.

In general, it was evident that almost two thirds of our physicians understand the items reflecting their knowledge about EBM, in contrast to what was found in a study conducted in Poland, where it was reported that the GP respondents' knowledge of epidemiological and statistical terms and of the valid study results was low. (13) This difference might be explained by the variation in composition of the study groups in the two studies, in addition to the training status of the physicians of the current study where it was shown that almost one fifth of the physicians had previous formal training in items pertinent to EBM.

In the same context, and as expected, the study revealed that the physicians who has previous formal training in search strategy and training in EBM had significantly better understanding the basics of EBM if compared to those who reported that they never attended such courses, the same findings were found in a study that was conducted in Iran, where it was reported that the knowledge score was higher in those with prior EBM training. (14) The impact of training on the ultimate outcome of the clinical practice might represent another facet of EBM practicing, this issue was investigated in a study which was conducted in Sweden which revealed that to change in the behavior of the physicians regarding the shift from individual to evidence based decisions require a consistent periodic booster training and the trainees should be convinced about the actual benefits gained from practicing EBM in their clinical sessions. (17)

The respondents of the study addressed that there were barriers facing them in practicing EBM, mainly lack of internet access at the work proximity, no time available, and shortage of handled scientific educational materials e.g. updated magazines and journal. In an attempt to disseminate the concept and practicing EBM, several studies had been conducted to elaborate the obstacles that that hinder its practice, In the study conducted in Riyadh city, KSA, (9) it was cited that there were barriers facing the physicians in practicing EBM, and same findings were found in AL Taif city, KSA. (10) The findings of the current study was in accordance with what was found in a study conducted in Malaysia where it was found that the main barriers to practicing EBM were lack of personal time and lack of Internet access in the primary care clinics. (15)Also, in England (12), and Canada (18) in a studies conducted for the same purpose, they reported similar findings. While the barriers indicated by the physicians in the current study and its comparable studies were related mostly to the resources empowering EBM practicing, nevertheless, even those who had available resources they articulated another in depth obstacles which were represented by difficulties in the fundamental approaches for practicing EBM as formulating clinical questions and critical appraisal (19). Which ultimately mean that the challenge of barriers that facing EBM practicing is prevailing regionally and internationally in various health institution and in various aspects of EBM.

Conclusions:

Although the physicians showed acceptable level of knowledge about EBM, nevertheless there was a gap between their knowledge and practice, and this gap could be attributed to what was addressed by the physicians that there were barriers facing their practice of EBM namely, inadequacy of time and unavailability of access to internet in their working place. The relatively better knowledge of the trained than the untrained physicians could draw the attention towards the importance of training courses pertinent to EBM.

Recommendation:

1. Training courses related to EBM issues should be incorporated in the continuous medical education programs in an attempt to shift from the individual to evidence based practices.

2. Essential resources needed for practicing EBM should be provided to all health institutes especially the computer sets, internet access and subscription on reasonable sources of evidenced databases.

3. Simplified techniques and programs should be established to facilitate beside-bed access to the evidenced sources of information to different health professionals.

Table 1: Response of the physicians to the items reflecting their attitude towards EBM.

Socio-demographic Characteristics

Median score

p*

Age (years):

0.007

<30 years

7

30-39 Years

8

40-49 Years

8

50+ Years

9.5

Gender:

0.708

Males

8

Females

7

Job:

0.425

Surgery consultant

8

Surgery specialist

8

Surgery residents

8

Medical consultant

9

Medical specialist

8

Medical resident

9

PHC consultant

8

PHC specialist

8.5

PHC resident

8

Overall score

8

Having postgraduate board certificate:

0.159

Yes

8

No

8

Table 2: Perspective of the physicians about the preferable ways of moving from opinion based to evidence based practice according to their specialty

Preferable ways of shifting from opinion base to EBM

Department

Total

p*

PHC

Surgery

Medical

By learning the skills of EBM

Yes

24(33.8%)

15(21.7%)

12(17.1%)

51(24.3%)

0.058

No

47(66.2%)

54(78.3%)

58(82.9%)

159(75.7%)

By seeking and applying of EBM

Yes

29(40.8%)

28(40.6%)

48(68.6%)

105(50.0%)

0.001

No

42(59.2%)

41(59.4%)

22(31.4%)

105(50.0%)

EBM developed by colleagues

Yes

45(63.4%)

34(49.3%)

16(22.9%)

95(45.2%)

0.000

No

24(33.8%)

35(50.7%)

54(77.1%)

115(54.8%)

* Based on Chi Square

Barriers to practicing EBM as indicated by the physicians arranged in descending order. order.

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