Why is there variation in the practice of evidence-based medicine in primary care? A qualitative study

Evidence-based veterinary medicine-potential, practice, and pitfalls

Understanding and incorporating evidence-based veterinary medicine (EBVM) into clinical practice and research continues to pose a challenge for our profession despite over 2 decades of increasing awareness of this concept. Reasons for this include a lack of understanding of its importance to the practice of medicine, veterinary literature that often fails to adhere to evidence-based standards, inadequate attention to teaching EBVM at the university level, and the inherent reluctance of clinicians to alter historical practice styles. For many practitioners, EBVM continues to be an abstract concept they believe requires advanced training in statistics and epidemiology resulting in them relying on less robust sources for clinical guidance. This unfortunately results in suboptimal care for our patients and delayed medical advancements for our profession. As part of the 20th anniversary of the founding of the Evidence-Based Veterinary Medicine Association (EBVMA), we are refocusing our efforts to highlight the need for dedicated teaching of EBVM at the university level, for rigorous adherence to established research reporting guidelines, for expansion of EBVM infrastructure, and for the provision of easily accessible tools that permit clinicians to incorporate EBVM into their daily practice. As the quality of veterinary literature improves, so too will development of more effective clinical practice guidelines that ultimately can be widely adopted if they are flexible enough to support the triadic relationship between veterinarians, our clients and our patients. Ultimately, EBVM is not an end unto itself, but rather a means to improve the quality of care we provide our patients.

Knowledge of Human Monkeypox Virus Infection among Healthcare Providers and Associated Factors in Addis Ababa, Ethiopia

Human monkeypox virus infection (mpox) is a reemerging viral zoonotic disease that has been occurring outside of locations where it has been endemic in Africa. To understand the shifting epidemiology of this disease and respond accordingly, increased clinical skill and professional capabilities are essential. However, there are no studies assessing the knowledge of healthcare professionals in Ethiopia on mpox. Hence, this paper aimed to assess knowledge of the infection and associated factors among healthcare providers in Addis Ababa, Ethiopia, specifically knowledge of diagnosis and treatment of mpox, from November 14, 2022 to November 25, 2022. A facility-based cross-sectional study design was used. Knowledge was assessed using a structured questionnaire, and a 70% Bloom's cutoff point was used to classify the scores. A pretest was conducted in a similar setting before data collection. Frequencies, percentages, and bivariate and multivariate logistic regression analyses were used. The majority of participants, 128 (64.6% with 95% CI), scored below 70% on knowledge questions. Professionals with experience of 5 years or less had better knowledge than those who had worked longer (adjusted odds ratio: 0.301; 95% CI: 0.149-0.609; P = 0.000). Knowledge of mpox among healthcare providers in Addis Ababa was poor across sociodemographic and professional variables. Thus, education on mpox among healthcare providers in Ethiopia is critical in preparing the workforce and limiting potential damage to the country.

Abstracts of randomized controlled trials in splint therapy for temporomandibular disorders: Reporting quality and spin

BACKGROUND

Poor reporting quality and spin in randomized controlled trial (RCT) abstracts can lead to misinterpretation and distorted interpretation of results.

OBJECTIVES

This methodological study aimed to assess the reporting quality and spin among RCT abstracts on splint therapy for temporomandibular disorders (TMD) and explore the association between spin and potentially related factors.

METHODS

The authors searched PubMed for RCTs on splint therapy for TMD. The reporting quality of each abstract was assessed using the original 16-item CONSORT for abstracts checklist. The authors evaluated the presence and characteristics of spin only in abstracts with nonsignificant primary outcomes according to pre-determined spin strategies. Logistic regression analyses were performed to identify factors associated with the presence of spin.

RESULTS

A total of 148 abstracts were included in the reporting quality evaluation. The mean overall CONSORT score (OCS) was 5.86 (score range: 0-16). Only interventions, objectives and conclusions were adequately reported. Of the 61 RCT abstracts included for spin analysis, spin was identified in 38 abstracts (62.3%), among which 32 abstracts (52.3%) had spin in the Results section and 21 (34.4%) had spin in the Conclusions section. A significantly lower presence of spin was found in studies with exact p-value reporting (OR: 0.170; 95% CI: 0.032-0.887; p = .036) and a two-arm comparison design (OR: 11.777; 95% CI: 2.171-63.877; p = .004).

CONCLUSIONS

The reporting quality of RCT abstracts on splint therapy for TMD is suboptimal and the prevalence of spin is high. More awareness and joint efforts are needed to improve reporting quality and minimize spin.

The preparedness and knowledge of pharmacists and general practitioners in managing human monkeypox: a highly spreading infectious disease

BACKGROUND

After the era of the COVID-19 pandemic, the role of pharmacists was emphasized in the battle against highly spreading and infectious diseases like human Monkeypox (hMPV).

AIM

Assess the hMPV knowledge of the community, clinical pharmacists, and general practitioners (GPs) and raise their awareness about hMPV.

METHODS

A web-based questionnaire was distributed randomly to Egyptian community pharmacists, clinical pharmacists, and GPs from all governorates. The questionnaire was divided into two sections: one for demographic information and the other for hMPV knowledge (nature of the disease, incubation period, transmission, symptoms, Prophylaxis, Prevention, and management). The evidence-based answers were provided after completing the submission. Data were descriptively analyzed using IBM SPSS software.

RESULTS

From a total of 753 respondents, only 710 participants were included in the final data analysis. The % of respondents who presented good total knowledge scores about hMPV was comparable between study groups (P = 0.826). There were no differences between groups identifying different disease clinical characteristics (P = 0.689) and hMPV management (P = 0.324). Community pharmacists had better knowledge scores than GPs in the prevention and prophylaxis domain (P = 0.037).

CONCLUSION

Pharmacists and GPs have good and similar knowledge levels of hMPV. However, a gap exists in recognizing the right hMPV incubation period, prophylaxis, and omitting antibiotics from hMPV management. Pharmacists and GPs are the frontline health care providers (HCPs), so they would require more knowledge enhancement about such contagious diseases to offer the best possible patient care.

Evaluation of human monkeypox knowledge and beliefs regarding emerging viral infections among healthcare workers

OBJECTIVES

The purpose of this study was to evaluate possible factors that might be accompanied by high level of human monkey pox (HMPX) knowledge and to explain the relationship between HMPX knowledge and Beliefs regarding emerging viral infections.

STUDY DESIGN

A descriptive cross-sectional study was conducted for the implementation of this study.

METHODS

Study was conducted at two general hospitals in Mansoura City (Old General Hospital and International Hospital) El Dakahlia Governorate among 620 healthcare workers (HCWs) using a self-managed questionnaire for 1 week (1 to 7 January 2023). The questionnaire has items adapted from the previously published literature to assess HMPX knowledge and Beliefs regarding emerging viral infections.

RESULTS

The mean age of the study sample was 27.97 years and most of them were female (86.1%). Physicians and other HCWs (nurses, laboratory technicians, radiographer technicians, and pharmacists) had significantly different levels of knowledge of monkeypox for the majority of the questions. A higher belief was found among two items: viruses are biological weapons manufactured by the superpowers to take global control and the government is misleading the public about the cause of the virus.

CONCLUSION

This study discovered lower levels of knowledge of HMPX among HCWs in Egypt. Beliefs about emerging viral infections were widespread, and future research should look into their potential negative impact on health behavior.

Knowledge of mpox and its determinants among the healthcare personnel in Arabic regions: A multi-country cross-sectional study

Background & aim

The monkeypox virus (MPXV), an Orthopoxvirus family member, is the zoonotic agent that causes mpox (formerly known as monkeypox). The ongoing mpox pandemic has caused cases across continents involving 110 countries. This study aimed to assess mpox knowledge and its determinants among healthcare personnel.

Methods

This cross-sectional study was conducted from June 6 to June 25, 2022, among 17 Arab countries. The self-administered questionnaire consists of 53 questions assessing the knowledge about the monkeypox virus.

Results

In total, 5874 medical students and clinical doctors from 17 Arab countries participated in this study. Only 13.8% (n = 812) of respondents have ever received information about mpox during their studies in medicine. The mean knowledge score was 13.84, and the median score was 15 (range 1-34). More than half (51.3%, n = 3012) have heard about mpox before. A low proportion of the participants had a good level of knowledge on mpox. Only 11.7% of respondents had correctly identified the natural host and the incubation period of mpox. More than half (58.9%) were aware of the signs and symptoms of mpox. Few respondents (28%) believed that mpox and smallpox have similar signs and symptoms. Specialist doctors had higher knowledge of mpox (AOR = 2.96, 95% CI = 2.24-3.92, p < 0.001) than other cadres.

Conclusion

Mpox awareness among Arabic medical students and practitioners is low; hence immediate action in creating awareness among arab healthcare professionals is the need of the hour. This is crucial in the mpox early detection and prevention of its spread.

Assessment of risk perception and subjective norms related to Mpox (monkeypox) among adult males in Bangladesh: A cross-sectional study

Background and Aims

Monkeypox (Mpox) has become a concern worldwide after spreading into nonendemic countries. The World Health Organization (WHO) has declared this a public health emergency of international concern and recommended to get vaccinated first who are at the highest risk. Risk perception and subjective norms can influence the decision of vaccine uptake. Therefore, we intended to perform a cross-sectional study on the male population in our country to assess their risk perception and subjective norms on Mpox.

Methods

We measured participants' risk perception and subjective norms using Google form. Demographic profile of participants was obtained using a structured questionnaire. We performed a χ 2 test to compare the levels of risk perception and subjective norm perception and multiple logistic regression analysis to determine the association between the study parameters and the sociodemographic profile of the participants.

Results

Among the participants, 93 (23.72%), 288 (73.47%), and 11 (2.81%) had high, medium, and low-risk perceptions, respectively. For subjective norms, we observed 288 (58.16%) participants had a medium, 117 (29.85%) had high, and 47 (11.99%) had low levels of subjective norms, respectively. Most participants possessed medium risk perception (73.47%) and subjective norms (58.16%). Moreover, we observed that moderate risk perception was prevalent in people with body mass index (BMI) level between 18.5 and 25 (73.3%), married (63.5%), low economic background (94.1%), living with a family (77.1%), smokers (68.4%), heterosexuals (99%), people with no/little impact of coronavirus disease 2019 (Covid-19) on life (91%). Proportions of people with moderate subjective norms BMI level of 18.5-25 (73.2%), married (60.5%), low economic status (93.9%), rural (58.8%), living with family (77.2%), nonsmokers (71.1%), and people with no/little impact of Covid-19 in their lives (91.2%).

Conclusion

The majority of participants perceived medium risk perception and subjective norms related to Mpox. Furthermore, we observed a significant association between the study parameters and the sociodemographic characteristics of our study participants. We recommend that further longitudinal studies to yield more accurate results.

Barriers and Facilitators to Implementing Cost-Effective Evidence-Based Childhood Cancer Treatment in a Resource-Limited Setting in Egypt: A Qualitative Interview Study

PURPOSE

Childhood cancer treatment is complex, resource-intensive, and expensive, and resource-limited settings would benefit from providing cost-effective treatment approaches on the basis of evidence. Effective implementation of cost-effective evidence-based treatment requires knowledge about factors influencing its use. In this study, we determined the clinicians' perceptions of the barriers and facilitators to implementing cost-effective evidence-based treatment for children with cancer in a resource-limited pediatric oncology setting in Egypt.

METHODS

We conducted a qualitative study on the basis of semistructured interviews with senior clinicians who make high-level decisions on treatment protocols and tailored decisions for the atypically complicated group of patients. Purposive sampling was used to recruit the participants. Thematic analysis was conducted semantically to develop themes of barriers and facilitators.

RESULTS

Fourteen participants agreed to participate in the study: nine pediatric oncologists; three surgeons; and two radiation oncologists. We identified four main themes of barriers and facilitators: awareness and orientation; knowledge, skills, and attitudes; system, resources, and context; and clinical practice. The main barriers included absence of easily available costs/cost-effectiveness data, limited resources and inability to pay for expensive novel (cost-effective) drugs, and gap between evidence and practice. The main facilitators included adopting standard treatment protocols on the basis of clinical effectiveness, leadership support, availability of patients' clinical and cost data from local context, and existing knowledge and skills in clinical research and health economic evaluation. The interview participants also provided suggestions to promote the implementation of cost-effective evidence-based treatment in priority areas.

CONCLUSION

Our study findings provide an understanding of the barriers and facilitators affecting the implementation of cost-effective evidence-based treatment for childhood cancers in Egypt. We provide practical recommendations to address the implementation gaps with implications on practice, policy, and research.

The Application of Knowledge-Based Clinical Decision Support Systems to Enhance Adherence to Evidence-Based Medicine in Chronic Disease

Among the technology-based solutions, clinical decision support systems (CDSSs) have the ability to keep up with clinicians with the latest evidence in a smart way. Hence, the main objective of our study was to investigate the applicability and characteristics of CDSSs regarding chronic disease. The Web of Science, Scopus, OVID, and PubMed databases were searched using keywords from January 2000 to February 2023. The review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Then, an analysis was done to determine the characteristics and applicability of CDSSs. The quality of the appraisal was assessed using the Mixed Methods Appraisal Tool checklist (MMAT). A systematic database search yielded 206 citations. Eventually, 38 articles from sixteen countries met the inclusion criteria and were accepted for final analysis. The main approaches of all studies can be classified into adherence to evidence-based medicine (84.2%), early and accurate diagnosis (81.6%), identifying high-risk patients (50%), preventing medical errors (47.4%), providing up-to-date information to healthcare providers (36.8%), providing patient care remotely (21.1%), and standardizing care (71.1%). The most common features among the knowledge-based CDSSs included providing guidance and advice for physicians (92.11%), generating patient-specific recommendations (84.21%), integrating into electronic medical records (60.53%), and using alerts or reminders (60.53%). Among thirteen different methods to translate the knowledge of evidence into machine-interpretable knowledge, 34.21% of studies utilized the rule-based logic technique while 26.32% of studies used rule-based decision tree modeling. For CDSS development and translating knowledge, diverse methods and techniques were applied. Therefore, the development of a standard framework for the development of knowledge-based decision support systems should be considered by informaticians.

Critically Appraising Pragmatist Critiques of Evidence-Based Medicine: Is EBM Defensible on Pragmatist Grounds?

Significant contributions to debates in the philosophy of evidence-based medicine (EBM) have come from a variety of different philosophical quarters, yet mainstream discourse in the field has been largely devoid of contributions from scholars working in the pragmatist tradition. This is a particularly conspicuous omission, given pragmatism's commitment to the melioristic view that philosophy both can, and should, be about the business of concretely bettering the human estate. Two exceptions to this oversight come from Brian Walsh and Maya Goldenberg. Unfortunately, in both cases, the misapplication of pragmatist thinking leads to the mistaken view that EBM is committed to some form of pernicious objectivism. This article aims to revise these pragmatist critiques in order to bring them more consistently in line with pragmatist values and commitments. Doing so shows that EBM is defensible on pragmatist grounds against objectivist attacks.

Knowledge, Attitude, and Practice towards Evidence-Based Medicine among Northern Saudi Primary Care Physicians: A Cross-Sectional Study

The evidence-based practice of primary care physicians is essential because they are the first line of contact with the local community, and they cater to most of their communities’ health needs. In the current study, in which we used a cross-sectional survey in northern Saudi Arabia, we assessed primary care physicians’ knowledge, attitude, practice, and barriers regarding evidence-based medicine (EBM). Of the 300 physicians who participated, less than half had high knowledge (43.7%) and attitude (47.7%) toward EBM. The chi-square test revealed that the knowledge categories were significantly associated with the age group (p = 0.002) and EBM training received in the past five years (p < 0.001), and the attitude categories were significantly associated with nationality (p = 0.008). Of the respondents, 155 (51.7%) used EBM in their daily clinical practice. Through logistic regression analysis, we found that the identified predictors of including EBM in clinical practice were the 31−45-year-old age group (adjusted odds ratio (AOR) = 2.11, 95% confidence interval (CI) = 1.65−2.73) and EBM training received during last 5 years (AOR = 2.12, 95% CI = 1.35−2.94). We recommend enhancing primary care physicians’ knowledge of EBM and its importance in clinical practice through appropriate training programs. A multi-centric mixed-method survey is warranted in other provinces of the KSA to recognize region-specific training demand.

Online Searching as a Practice for Evidence-Based Medicine in the Neonatal Intensive Care Unit, University of Malaya Medical Center, Malaysia: Cross-sectional Study

Background

The use of the internet for research is essential in the practice of evidence-based medicine. The online search habits of medical practitioners in clinical settings, particularly from direct observation, have received little attention.

Objective

The goal of the research is to explore online searching for information as an evidence-based practice among medical practitioners.

Methods

A cross-sectional study was conducted to evaluate the clinical teams’ use of evidence-based practice when making clinical decisions for their patients' care. Data were collected through online searches from 2015 to 2018. Participants were medical practitioners and medical students in a Malaysian public teaching hospital’s neonatal intensive care unit who performed online searches to find answers to clinical questions that arose during ward rounds.

Results

In search sessions conducted by the participants, 311 queries were observed from 2015 to 2018. Most participants (34/47, 72%) were house officers and medical students. Most of the searches were conducted by house officers (51/99, 52%) and medical students (32/99, 32%). Most searches (70/99, 71%) were directed rather than self-initiated, and 90% (89/99) were completed individually rather than collaboratively. Participants entered an average of 4 terms in each query; three-quarters of the queries yielded relevant evidence, with two-thirds yielding more than one relevant source of evidence.

Conclusions

Our findings suggest that junior doctors and medical students need more training in evidence-based medicine skills such as clinical question formulation and online search techniques for performing independent online searches effectively. However, because the findings were based on intermittent opportunistic observations in a specific clinical setting, they may not be generalizable.

Misleading Reporting (Spin) in Noninferiority Randomized Clinical Trials in Oncology With Statistically Not Significant Results: A Systematic Review

IMPORTANCE

Spin, the inaccurate reporting of randomized clinical trials (RCTs) with results that are not statistically significant for the primary end point, distorts interpretation of results and leads to misinterpretation. However, the prevalence of spin and related factors in noninferiority cancer RCTs remains unclear.

OBJECTIVE

To examine misleading reporting, or spin, and the associated factors in noninferiority cancer RCTs through a systematic review.

DATA SOURCES

A systematic search of the PubMed database was performed for articles published between January 1, 2010, and December 31, 2019, using the Cochrane Highly Sensitive Search Strategy.

STUDY SELECTION

Two investigators independently selected studies using the inclusion criteria of noninferiority parallel-group RCTs aiming to confirm effects to cancer treatments published between January 1, 2010, and December 31, 2019, reporting results that were not statistically significant for the primary end points.

DATA EXTRACTION AND SYNTHESIS

Standardized data abstraction was used to extract information concerning the trial characteristics and spin based on a prespecified definition. The main investigator extracted the trial characteristics while both readers independently evaluated the spin. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.

MAIN OUTCOMES AND MEASURES

The main outcome was spin prevalence in any section of the report. Spin was defined as use of specific reporting strategies, from whatever motive, to highlight that the experimental treatment is beneficial, despite no statistically significant difference for the primary outcome, or to distract the reader from results that are not statistically significant. The associations (prevalence difference and odds ratios [ORs]) between spin and trial characteristics were also evaluated.

RESULTS

The analysis included 52 of 2752 reports identified in the PubMed search. Spin was identified in 39 reports (75.0%; 95% CI, 61.6%-84.9%), including the abstract (34 reports [65.4%; 95% CI, 51.1%-76.9%]) and the main text (38 reports [73.1%; 95% CI, 59.7%-83.3%]). Univariate analysis found that the spin prevalence was higher in reports with data managers (prevalence difference, 27%; 95% CI, 1.1%-50.3%), reports without funding from for-profit sources (prevalence difference, 31.2%; 95% CI, 4.8%-53.8%), and reports of novel experimental treatments (prevalence difference, 37.5%; 95% CI, 5.8%-64.7%). Multivariable analysis found that novel experimental treatment (OR, 4.64; 95% CI, 0.98-22.02) and funding only from nonprofit sources only (OR, 5.20; 95% CI, 1.21-22.29) were associated with spin.

CONCLUSIONS AND RELEVANCE

In this systematic review, most noninferiority RCTs reporting results that were not statistically significant for the primary end points showed distorted interpretation and inaccurate reporting. The novelty of an experimental treatment and funding only from nonprofit sources were associated with spin.

Determining the Value-Efficiency of Respiratory Care

In order to determine, document, and communicate the value of respiratory therapists performing respiratory care procedures, the respiratory care profession needs to position itself to capture and report both time and value standards that can be applied in allocating respiratory care resources. To do this, we propose a new metric called value-efficiency. If we wish to use value-efficiency as a metric to justify respiratory care activities and support labor budgets, there are three key considerations: (1) What value does respiratory care add to the health care organization? (2) Are the interventions provided necessary and of clinical value? (3) What is the value of the respiratory therapist in the delivery of these services? Significant challenges are facing the respiratory care profession and a focus on value-efficiency is a direction the profession must pursue. This approach is a practical response to the increasing demands of payers, administrators, consultants, and patients.

Knowledge, Attitude, and Practice of Evidence-Based Medicine among Emergency Doctors in Kelantan, Malaysia

This study aimed to determine the prevalence of high levels of knowledge, positive attitude, and good practice on evidence-based medicine (EBM) and identify the associated factors for practice score on EBM among emergency medicine doctors in Kelantan, Malaysia. This cross-sectional study was conducted in government hospitals in Kelantan. The data were collected from 200 emergency physicians and medical officers in the emergency department using the Noor Evidence-Based Medicine Questionnaire. Simple and general linear regressions analyses using SPSS were performed. A total of 183 responded, making a response rate of 91.5%. Of them, 49.7% had a high level of knowledge, 39.9% had a positive attitude and 2.1% had good practice. Sex, race, the average number of patients seen per day, internet access in workplace, having online quick reference application, and attitude towards EBM were significantly associated with EBM practice scores. It is recommended that appropriate authorities provide emergency doctors with broader access to evidence resources. EBM skill training should be enhanced in the current medical school curriculums.

Addressing barriers to the conduct and application of research in complementary and alternative medicine: a scoping review

BACKGROUND

Over the past few decades, the popularity of complementary and alternative medicine (CAM) has grown considerably and along with it, scrutiny regarding its evidence base. While this is to be expected, and is in line with other health disciplines, research in CAM is confronted by numerous obstacles. This scoping review aims to identify and report the strategies implemented to address barriers to the conduct and application of research in CAM.

METHODS

The scoping review was undertaken using the Arksey and O'Malley framework. The search was conducted using MEDLINE, EMBASE, EMCARE, ERIC, Scopus, Web of Science, The Cochrane Library, JBI and the grey literature. Two reviewers independently screened the records, following which data extraction was completed for the included studies. Descriptive synthesis was used to summarise the data.

RESULTS

Of the 7945 records identified, 15 studies met the inclusion criteria. Using the oBSTACLES instrument as a framework, the included studies reported diverse strategies to address barriers to the conduct and application of research in CAM. All included studies reported the use of educational strategies and collaborative initiatives with CAM stakeholders, including targeted funding, to address a range of barriers.

CONCLUSIONS

While the importance of addressing barriers to the conduct and application of research in CAM has been recognised, to date, much of the focus has been limited to initiatives originating from a handful of jurisdictions, for a small group of CAM disciplines, and addressing few barriers. Myriad barriers continue to persist, which will require concerted effort and collaboration across a range of CAM stakeholders and across multiple sectors. Further research can contribute to the evidence base on how best to address these barriers to promote the conduct and application of research in CAM.

Knowledge, attitude and practice of evidence-based medicine among primary care practitioners in Malaysia: a cross-sectional study

OBJECTIVES

To determine the level of knowledge and practice of evidence-based medicine (EBM) and the attitudes towards it and to identify the factors associated with its practice among primary care practitioners in Selangor, Malaysia.

SETTING

This cross-sectional study was conducted in randomly selected health clinics in Selangor. Data were collected from primary care physicians using self-administered questionnaires on knowledge, practice and attitudes regarding EBM.

PARTICIPANTS

The study included 225 respondents working in either government or private clinics. It excluded house officers and those working in public and private universities or who were retired from practice.

RESULTS

A total of 32.9% had a high level of EBM knowledge, 12% had a positive attitude towards EBM and 0.4% had a good level of its practice. The factors significantly associated with EBM practice were ethnicity, attitude, length of work experience as a primary care practitioner and quick access to online reference applications on mobile phones.

CONCLUSIONS

Although many physicians have suboptimal knowledge of EBM and low levels of practising it, majority of them have a neutral attitude towards EBM practice. Extensive experience as a primary care practitioner, quick access to online references on a mobile phone and good attitude towards EBM were associated with its practice.

Factors affecting management of children's low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study

BACKGROUND

Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently.

METHODS

We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management.

RESULTS

We analyzed 70 801 fractures. A total of 20.8% (n = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up.

INTERPRETATION

While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.

Sane and safe: Forced social distancing to prevent human-to-human transmission of COVID-19

The current outbreak of COVID-19, originating from the city of Wuhan in China and ultimately involving over 200 countries, is now a global concern. Evidence indicates that COVID-19 spread to humans from wild animals, causing severe respiratory tract infections in humans; the typical symptoms of COVID include cough, high-grade fever, sore throat, and difficulty in breathing. The infection spreads from human to human via droplets. Therefore, social or physical distancing can reduce spread within communities. Asymptomatic spread can also occur during family gatherings or in the workplace; thus, we must enforce physical distancing as much as possible to reduce the spread of cases.

A Clinical Decision Support System (KNOWBED) to Integrate Scientific Knowledge at the Bedside: Development and Evaluation Study

BACKGROUND

The evidence-based medicine (EBM) paradigm requires the development of health care professionals' skills in the efficient search of evidence in the literature, and in the application of formal rules to evaluate this evidence. Incorporating this methodology into the decision-making routine of clinical practice will improve the patients' health care, increase patient safety, and optimize resources use.

OBJECTIVE

The aim of this study is to develop and evaluate a new tool (KNOWBED system) as a clinical decision support system to support scientific knowledge, enabling health care professionals to quickly carry out decision-making processes based on EBM during their routine clinical practice.

METHODS

Two components integrate the KNOWBED system: a web-based knowledge station and a mobile app. A use case (bronchiolitis pathology) was selected to validate the KNOWBED system in the context of the Paediatrics Unit of the Virgen Macarena University Hospital (Seville, Spain). The validation was covered in a 3-month pilot using 2 indicators: usability and efficacy.

RESULTS

The KNOWBED system has been designed, developed, and validated to support clinical decision making in mobility based on standards that have been incorporated into the routine clinical practice of health care professionals. Using this tool, health care professionals can consult existing scientific knowledge at the bedside, and access recommendations of clinical protocols established based on EBM. During the pilot project, 15 health care professionals participated and accessed the system for a total of 59 times.

CONCLUSIONS

The KNOWBED system is a useful and innovative tool for health care professionals. The usability surveys filled in by the system users highlight that it is easy to access the knowledge base. This paper also sets out some improvements to be made in the future.

Skills, attitudes and uptake of evidence-based practice: a cross-sectional study of chiropractors in the Swedish Chiropractic Association

Background

Evidence-based practice (EBP) is integral to the delivery of high-quality health care. Chiropractic has been a licensed health profession in Sweden since 1989, but little is known of the uptake of EBP in this professional group. This study explored the self-reported skills, attitudes and uptake of EBP, and the enablers and barriers of EBP uptake, among licensed chiropractors in Sweden.

Methods

Licensed chiropractors (n = 172) of the Swedish Chiropractic Association (Legitimerade Kiropraktorers Riksorganisation) were invited to participate in an anonymous online questionnaire, using the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) in February 2019.

Results

Fifty-six (33%) chiropractors completed the survey. Participants were predominantly male, aged 30–49 years, held a Master’s degree, and had received their highest qualification and practiced chiropractic for over a decade. Chiropractors rated their EBP skill-level mostly in the moderate to moderate-high range. The majority of chiropractors reported positive attitudes towards EBP, with most agreeing or strongly agreeing that EBP is necessary in the practice of chiropractic, and that EBP assists in making decisions about patient care. Chiropractors reported an average level of engagement in EBP activities. All participants indicated professional literature and research findings were useful in their day-to-day chiropractic practice. The main perceived enabler of EBP uptake was internet access in the workplace, whereas the main barrier to EBP uptake was lack of clinical evidence in chiropractic.

Conclusions

Participating chiropractors of the Swedish Chiropractic Association were generally favourable of EBP, though only reported modest levels of EBP-related skills and engagement in EBP activities. Our findings suggest future studies investigating interventions focussed on improving chiropractors’ skills and uptake of EBP are warranted.

The use of vitamin D in preventing post-thyroidectomy hypocalcemia: An endocrinologist survey study

OBJECTIVE

To evaluate the use of preoperative vitamin D levels and postoperative vitamin D supplementation among endocrinologists for the prevention of post-thyroidectomy hypocalcaemia.

METHODS

Endocrinologist members of the American Thyroid Association (ATA) were contacted via email to complete a 21-question survey, which included both questions about demographic information, and preventing and managing postoperative hypocalcaemia after thyroidectomy. Univariate and multivariate analysis was performed to determine the respondents' use of preoperative vitamin D levels, dose and duration of preoperative vitamin D repletion, decision to delay surgery for low vitamin D levels in the case of a benign or malignant disease, and routine prescription of postoperative calcium or vitamin D supplementation.

RESULTS

225 endocrinologists who were ATA members responded to the questionnaire. When compared to endocrinologists practicing in other countries, those that practice in the United States were 2.5 times more likely to check preoperative vitamin D levels (95% CI[1.404, 4.535], P = .002), significantly more likely to replete vitamin D deficient patients with high-dose vitamin D (ie ≥50K IU/week), 4.458 times more likely to prescribe prophylactic supplemental calcium (95% CI[2.446, 8.126]; P < .0001) and 3.48 more likely to prescribe supplemental vitamin D (95% CI [1.906, 6.355]; P < .0001). Endocrinologists who have been in practice for >10 years were also 1.915 times more likely to prescribe supplemental vitamin D (95% CI (1.080, 3.395); P = .0263). Physicians that treat >50 thyroidectomy cases/year were 2.083 more likely to recommend a vitamin D repletion duration of >1 month than those that treat ≤50 cases/year ([1.036, 4.190], P = .0395). Lastly, if the patient has low preoperative vitamin D levels, 47.05% of respondents chose to delay surgery in a benign disease, while only 11.61% of respondents would do so in a case of malignant disease.

CONCLUSIONS

Approximately one-half of surveyed endocrinologists reported using preoperative vitamin D levels to assess a patient's risk for post-thyroidectomy hypocalcaemia. Endocrinologists practicing in the United States, compared to those practicing in other countries, were more likely to both test for preoperative vitamin D levels and to recommend prophylactic post-thyroidectomy calcium and vitamin D supplementation.

National Physician Survey for Nonvalvular Atrial Fibrillation (NVAF) Anticoagulation Comparing Knowledge, Attitudes and Practice of Cardiologist to PCPs

Introduction:

NVAF is estimated to affect between 6.4 and 7.4 million Americans in 2018, and increases the risk of stroke 5-fold. To mitigate this risk, guidelines recommend anticoagulating AF patients unless their stroke risk is very low. Despite these recommendations, 30.0-60.0% of NVAF patients do not receive indicated anticoagulation. To better understand why this may be, we surveyed PCPs and cardiologists nationwide on their attitudes, knowledge and practices toward managing NVAF with warfarin and direct-acting oral anticoagulants (DOACs).

Methods:

We surveyed 1,000 PCPs and 500 cardiologists selected randomly from a master list of the American Medical Association, using a paper based, anonymous, self-administered, mailed scannable survey. The survey contained questions on key demographics and data concerning attitudes, knowledge and practices related to prescribing DOACs. The surveys went out in the fall/winter of 2017-8 with a $10 incentive gift card. Survey responses were scanned into an Excel database and analyzed using SAS 9.3 (Cary, NC) for descriptive and inferential statistics.

Results:

Two hundred and forty-nine providers (167 PCPs, 82 cardiologists) participated in the study with a response rate of 18.8% (249/1320). Respondent mean years ±SD of experience since completing residency was 23.2 ± 13.8. Relative to cardiologists, less PCPs use CHADsVASC (36.8% vs. 74.4%) (p < 0.0001); more have never used HAS-BLED, HEMORR2HAGES, or ATRIA (38.5% vs. 9.8%) (p < .0001); more felt that their lack of knowledge/experience with DOACs was a barrier to prescribing the agents (p = 0.005); and more reported that they could use additional education on DOACs (87.0% vs. 47.0%) (p < 0.0001). Overall, cardiologists were more concerned about ischemic stroke outcomes, while PCPs were more concerned with GI bleeding. Cardiologists also felt that clinical trial data were most helpful in choosing the most appropriate DOAC for their patients, while PCPs felt that Real World Data was most useful.

Conclusions:

Cardiologists were more concerned with ischemic stroke while anticoagulating patients and utilized screening instruments like CHADsVASC in a majority of their patients. PCPs were concerned with GI bleeds when anticoagulating but nearly 40.0% utilized no screening tools to assess bleeding risk. Our findings show that future education about DOACs would be warranted especially with PCPs.

Awareness, attitudes, barriers, and knowledge about evidence-based medicine among family physicians in Croatia: a cross-sectional study

BACKGROUND

Evidence-based medicine (EBM) aims to assist physicians in making medical decisions based on the integration of the current best evidence, clinical expertise, and patients' values. Extensive research has been conducted regarding physicians' awareness, attitudes, barriers, and knowledge about EBM. In Croatia, there is a lack of research on this topic, especially among family physicians (FP). The aim of this study was to assess the awareness, attitudes, barriers, and knowledge about EBM among FPs in Croatia after six years of educational activities organized and provided by Cochrane Croatia.

METHODS

In a cross-sectional study, conducted in 2016, we offered to FPs in Croatia a printed or online validated questionnaire to assess attitudes toward and barriers when considering the use of EBM, awareness about sources of evidence, and their level of understanding of evidence-based medicine terminology. The physicians were approached during mandatory continuing medical education courses and through their professional associations. We compared results from two groups of physicians, one with family medicine specialization and the other without.

RESULTS

295 (14%) of all officially registered FPs responded to the questionnaire. Respondents were very positive toward the promotion and usage of EBM. 160 (67%) indicated that they did not have access to the Cochrane Library. The majority reported lack of time available for finding evidence (80%), and patients' unrealistic expectations that influence doctors' choice of treatment (72%). Between the two groups of physicians, more family medicine specialists reported time restrictions for finding evidence. The highest level of EBM terminology understanding was reported for study design terms, and the lowest for statistical terms.

CONCLUSIONS

This study demonstrated that FPs in Croatia had very positive attitudes toward the use of EBM, they agreed that EBM improves patient care, and they estimated that more than two thirds of their practice is EBM-based. Compared to the results of the first assessment of physicians in 2010, there was some increase in the level of EBM awareness among FPs. However, to further increase the quality of EBM practice in Croatia better access to EBM sources and further educational activities are needed.

Preventative and management strategies of hypocalcemia after thyroidectomy among surgeons: An international survey study

OBJECTIVE

To determine international surgeon practice patterns for transient postoperative hypocalcemia in patients undergoing total thyroidectomy.

METHODS

All member surgeons of the American Thyroid Association and the International Association of Thyroid Surgeons were contacted via email to complete a 20-question survey which included both questions about demographic information and preventing and managing postoperative hypocalcemia after thyroidectomy. Univariate analysis was performed to determine whether providers check preoperative vitamin D levels, postoperative calcium trends and/or PTH to assess for postoperative hypocalcemia.

RESULTS

A total of 332 surgeons responded to the survey with 72.26% in practice for >10 years and 82.18% performing >50 total thyroidectomies per year. 13.29% of surgeon's surveyed reported that they routinely check preoperative vitamin D levels. Surgeon case volume, type of practice (academic vs non-academic practice), and geographic location in the US were significant predictors of whether surgeons check preoperative Vitamin D levels. International surgeons were significantly more likely to check both postoperative serum Ca and PTH compared to US based surgeons (p < .01). There was no significance difference in practice patterns based on whether the surgeon was a General Surgeon or an Otolaryngologist.

CONCLUSIONS

Using a questionnaire distributed to both General Surgeons and Otolaryngologists, we demonstrated that there is significant variation in practice patterns between surgeons practicing in the United States and surgeons practicing in other countries, and practice often differs from recommended guidelines.

Knowledge of human monkeypox viral infection among general practitioners: a cross-sectional study in Indonesia

After the first, imported, laboratory-confirmed case of monkeypox in human was reported in Singapore on May 2019, countries in Asia started to strengthen disease surveillance systems. One challenge in preventing monkeypox is a lack of knowledge, particularly among healthcare workers. The aim of this study was to assess the knowledge of monkeypox among general practitioners (GPs) in Indonesia. A cross-sectional online survey was conducted. The survey collected participants' knowledge on a 21-item scale and explanatory variables. A two-step logistic regression analysis was employed to assess the predictors of knowledge of monkeypox. A total of 432 GPs were included; 10.0% and 36.5% of them had a good knowledge using an 80% and 70% cutoff point for knowledge domain, respectively. No explanatory variables were associated with knowledge when using 80% cutoff point. Using the lower cutoff, there was lower knowledge among GPs who graduated from universities located in Sumatra or other islands versus Java (adjusted odds ratio (aOR): 0.53; 95%CI: 0.28-0.97, p = 0.041) and among those were older than 30 years compared to younger GPs (aOR: 0.61; 95%CI: 0.39-0.96, p = 0.033). GPs working in private clinics had less knowledge compared to GPs in community health centers (aOR: 0.55; 95%CI: 0.31-0.99, p = 0.047). In conclusion, knowledge of monkeypox among GPs in Indonesia is relatively low in all groups. Increasing knowledge of monkeypox will be key to improving the capacity of GPs to respond to human monkeypox cases and to report into a disease surveillance system.

Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework

BACKGROUND

Insomnia is a common sleep complaint, with 10% of adults in the general population experiencing insomnia disorder, defined as lasting longer than three months in DSM-5. Up to 50% of patients attending family practice experience insomnia, however despite this, symptoms of insomnia are not often screened for, or discussed within this setting. We aimed to examine barriers to the assessment and diagnosis of insomnia in family practice from both the clinician and patient perspective.

METHODS

The present article identified research that has examined barriers to assessing insomnia from the clinician's and the client's perspectives following MEDLINE and Google Scholar searches, and then classified these barriers using the theoretical domains framework.

RESULTS

The most common barriers from the clinician's perspective were related to Knowledge, Skills, and the Environmental Context. From the patient perspective, barriers identified included their Beliefs about the consequences of Insomnia, Social Influences, and Behavioural Regulation of Symptoms.

CONCLUSIONS

Utilising this theoretical framework, we discuss options for bridging the gap between the identification and subsequent management of insomnia within the family practice setting. To assist clinicians and those in community health care to overcome the Knowledge and Skills barriers identified, this article provides existing relevant clinical criteria that can be utilised to make a valid diagnosis of insomnia.

Reducing Unneeded Clinical Variation in Sepsis and Heart Failure Care to Improve Outcomes and Reduce Cost: A Collaborative Engagement with Hospitalists in a MultiState System

OBJECTIVE

To (1) measure hospitalist care for sepsis and heart failure patients using online simulated patients, (2) improve quality and reduce cost through customized feedback, and (3) compare patient-level outcomes between project participants and nonparticipants.

METHODS

We conducted a prospective, quasi-controlled cohort study of hospitalists in eight hospitals matched with comparator hospitalists in six nonparticipating hospitals across the AdventHealth system. We provided measurement and feedback to participants using Clinical Performance and Value (CPV) vignettes to measure and track quality improvement. We then compared length of stay (LOS) and cost results between the two groups.

RESULTS

107 providers participated in the study. Over two years, participants improved CPV scores by nearly 8% (P < .001), with improvements in utilization of the three-hour sepsis bundle (46.0% vs 57.7%; P = .034) and ordering essential medical treatment elements for heart failure (58.2% vs 72.1%; P = .038). In study year one, average LOS observed/expected (O/E) rates dropped by 8% for participants, compared to 2.5% in the comparator group, equating to an additional 570 hospital days saved among project participants. In study year two, cost O/E rates improved from 1.16 to 0.98 for participants versus 1.14 to 1.01 in the comparator group. Based on these improvements, we calculated total cost savings of $6.2 million among study participants, with $3.8 million linked to system-wide improvements and an additional $2.4 million in savings attributable to this project.

CONCLUSIONS

CPV case simulation-based measurement and feedback helped drive improvements in evidence-based care that translated into lower costs and LOS, above-and-beyond other improvements at AdventHealth.

Cross-cultural Comparison of Pharmacy Students' Attitudes, Knowledge, Practice, and Barriers Regarding Evidence-based Medicine

Objective. To explore cultural influences on US and Japanese pharmacy students' evidence-based medicine (EBM) attitudes, knowledge, and behavior. Methods. A cross-sectional study was conducted using a self-administered survey. Senior students in one pharmacy school in the United States and two pharmacy schools in Japan were invited to complete a 33-item survey instrument. Results. Students in both countries reported having positive attitudes and understanding of EBM concepts. In their self-evaluation, American students rated their current EBM practice, EBM skills, and access to EBM resources higher than Japanese students rated themselves in these areas. The most common barriers to EBM for American students were lack of time (84.5%), lack of statistical knowledge (63.9%), and lack of critical appraisal skills (53.1%). The most common barriers to EBM for Japanese students were lack of training (92.6%), lack of clinical knowledge (90.4%), and lack of opportunity (88.8%). Conclusion. Although barriers to implementing EBM and confidence levels in using EBM differed between US and Japanese pharmacy students, both cohorts recognized EBM as an important skillset for the pharmacy profession. Culturally specific approaches to teaching EBM to pharmacy students are needed to improve EBM use in practice.

Decrease of variation in the grading of dysplasia in colorectal adenomas with a national e-learning module

AIMS

Variation in health-care is undesirable, as this is potentially harmful for patients. In the Netherlands, an e-learning module was developed to standardise pathological evaluation of colorectal adenomas. We studied the effect of e-learning on interlaboratory variability in grading of dysplasia in screened conventional colorectal adenomas.

METHODS AND RESULTS

A cross-sectional retrospective study was performed, including all colorectal adenomas from the Dutch population-based colorectal cancer screening programme, retrieved from the Dutch Pathology Registry (PALGA) from January 2014 to July 2015. The e-learning tool, commissioned by the National Institute for Public Health, was implemented among screening pathologists from October 2014. Proportions of high-grade dysplasia (HGD) were compared before (January-July 2014) and after implementation (October 2014-July 2015) of the e-learning module. Interlaboratory variation was assessed by multilevel mixed-effects analysis. In total, 20 713 colonoscopies (20 546 patients) were performed after a positive faecal immunochemical screening test, resulting in the inclusion of 56 355 conventional adenomas from 37 pathology laboratories. Before implementation, 12 614 adenomas were diagnosed, including 4.3% with HGD. After implementation, 43 741 adenomas were diagnosed, and the HGD proportion decreased to 3.9%. Univariable analysis showed less deviant proportions of HGD after implementation in 62% of the laboratories (P = 0.019). Multilevel analysis confirmed decreased variation in the risk of diagnosing HGD (P = 0.021).

CONCLUSIONS

Interlaboratory variability in grading HGD in colorectal adenomas after a positive screening test decreased after implementation of an e-learning module for pathologists. We therefore conclude that e-learning has a favourable influence on decreasing diagnostic variability, making this a relevant strategy for health-care standardisation.

Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions

Background

Healthcare costs are increasing in the USA and Canada and a substantial portion of health spending is devoted to services that do not improve health outcomes. Efforts to reduce waste by adopting evidence-based clinical practice guideline recommendations have had limited success. We sought insight into improving health system efficiency through understanding cardiologists’ perceptions of factors that influence clinical decision-making.

Methods

In this descriptive qualitative study, we conducted in-depth interviews with 18 American and 3 Canadian cardiologists. We used conventional content analysis including inductive and deductive approaches for data analysis and mapped findings to the ecological systems framework.

Results

Physicians reported that major determinants of practice included interpersonal interactions with peers, patients and administrators; financial incentives and system factors. Patients’ insurance status represented an important consideration for some cardiologists. Other major influences included time constraints, fear of litigation (less prominent in Canada), a sense that their obligation was never to miss any underlying pathology, and patient demands. The need to bring income into their health system influenced American cardiologists’ practice; personal income implications influenced Canadian cardiologists’ practice. Cardiologists reported that knowledge limitations and logistical challenges limit their ability to assist patients with cost considerations. All these considerations were more influential than guidelines; some cardiologists expressed a high level of scepticism regarding guidelines.

Conclusions

Clinical decision-making by cardiologists is shaped by individual, interpersonal, organisational, environmental, financial and sociopolitical influences and only to a limited extent by guideline recommendations. Successful strategies to achieve efficient, evidence-based care will require addressing socioecological influences on decision-making.

Unmasking the Practices of Nurses and Intercultural Health in Sub-Saharan Africa: A Useful Way to Improve Health Care?

In 2001 and 2013, the World Health Organization (WHO) published the WHO Traditional Medicine Strategy 2002-2005 and 2014-2023, respectively, to address policy, ethics, quality, and integration of complementary health therapies (CHT). Despite the adoption of these strategic frameworks, sub-Saharan African (SSA) countries largely run dualistic and inclusive health care system. A recent article published in Complementary Therapies in Clinical Practice analyzed the role of practicing nurses in CHT integration and intercultural health in an SSA country setting. Drawing on the Complementary and Alternative Medicine Health Belief Questionnaire, the study specifically examined nurses’ knowledge, practices, and attitudes toward CHT. The study revealed that nurses had low knowledge about CHT, which reflected in their ineptitude to engage in professional practices of CHT. In spite of the knowledge deficit, nurses generally held favorable attitudes toward CHT and the majority supported the need for “safe” and evidence-based integrative model. Efforts to improve CHT-related knowledge of nurses may enhance medical integration in SSA. This commentary proposes novel political will and investment in CHT education and research as well as an inclusion of CHT modules in the nurses’ training programs; viabilities to achieve intercultural health and improved care in SSA.

A comparison of evidence-based medicine practices between primary care physicians in rural and urban primary care settings in Malaysia: a qualitative study

OBJECTIVE

This study aimed to compare the evidence-based practices of primary care physicians between those working in rural and in urban primary care settings.

RESEARCH DESIGN

Data from two previous qualitative studies, the Front-line Equitable Evidence-based Decision Making in Medicine and Creating, Synthesising and Implementing evidence-based medicine (EBM) in primary care studies, were sorted, arranged, classified and compared with the help of qualitative research software, NVivo V.10. Data categories were interrogated through comparison between and within datasets to identify similarities and differences in rural and urban practices. Themes were then refined by removing or recoding redundant and infrequent nodes into major key themes.

PARTICIPANTS

There were 55 primary care physicians who participated in 10 focus group discussions (n=31) and 9 individual physician in-depth interviews.

SETTING

The study was conducted across three primary care settings-an academic primary care practice and both private and public health clinics in rural (Pahang) and urban (Selangor and Kuala Lumpur) settings in Malaysia.

RESULTS

We identified five major themes that influenced the implementation of EBM according to practice settings, namely, workplace factors, EBM understanding and awareness, work experience and access to specialist placement, availability of resources and patient population. Lack of standardised care is a contributing factor to differences in EBM practice, especially in rural areas.

CONCLUSIONS

There were major differences in the practice of EBM between rural and urban primary care settings. These findings could be used by policy-makers, administrators and the physicians themselves to identify strategies to improve EBM practices that are targeted according to workplace settings.

Implementation of a Novel Conference Series on Clinical Practice Variations Provides an Opportunity for Constructive Discussion of Faculty Practice Patterns: Do as We Say? … or Do as We Do?

BACKGROUND

Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions.

METHODS

Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV.

RESULTS

There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning.

CONCLUSION

Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."

Knowledge, attitude, and practice toward evidence-based medicine among hospital physicians in Qassim Region, Saudi Arabia

OBJECTIVES

To determine the knowledge, attitude, and practice regarding evidence-based medicine (EBM) among hospital physicians in Qassim region of Saudi Arabia.

METHODS

It is a cross-sectional study. A self-administered questionnaire survey was done among 288 physicians working in secondary and tertiary care centers. The study was conducted between June and September 2015.

RESULTS

The overall response rate for the survey was 72%. Majority of the respondents had a positive attitude toward EBM and welcomed the concept. A total of 83% respondents stated that they used EBM in their daily practice and 93.5% agreed that practicing EBM improves patient care. There was a moderate level of awareness regarding extracting information from journals and clinical evidence databases. Although the respondents were aware and demonstrated familiarity with the process of knowledge extraction procedures to determine the best care, as many as 40% did not use them. The respondents had a poor overall understanding of the technical terms used in EBM. Among the respondents, 38.5% thought that the best way to move from opinion-based medicine to EBM was through learning the skills of EBM. The factors that positively affected physician awareness included: Academic qualification and professional title. Knowledge and attitude were affected by qualification, professional title and specialty.

CONCLUSION

The attitude of most physician practitioners in this study is favorable toward EBM, but this was not correlated with knowledge and awareness. The inclusion of physician training courses in EBM concepts, technical terms and applied practice is highly recommended.

Influence of overstated abstract conclusions on clinicians: a web-based randomised controlled trial

OBJECTIVES

To investigate whether overstatements in abstract conclusions influence primary care physicians' evaluations when they read reports of randomised controlled trials (RCTs) DESIGN: RCT setting: This study was a parallel-group randomised controlled survey, conducted online while masking the study hypothesis.

PARTICIPANTS

Volunteers were recruited from members of the Japan Primary Care Association in January 2017. We sent email invitations to 7040 primary care physicians. Among the 787 individuals who accessed the website, 622 were eligible and automatically randomised into 'without overstatement' (n=307) and 'with overstatement' (n=315) groups.

INTERVENTIONS

We selected five abstracts from published RCTs with at least one non-significant primary outcome and overstatement in the abstract conclusion. To construct a version without overstatement, we rewrote the conclusion sections. The methods and results sections were standardised to provide the necessary information of primary outcome information when it was missing in the original abstract. Participants were randomly assigned to read an abstract either with or without overstatements and asked to evaluate the benefit of the intervention.

OUTCOME MEASURES

The primary outcome was the participants' evaluation of the benefit of the intervention discussed in the abstract, on a scale from 0 to 10. A secondary outcome was the validity of the conclusion.

RESULTS

There was no significant difference between the groups with respect to their evaluation of the benefit of the intervention (mean difference: 0.07, 95% CI -0.28 to 0.42, p=0.69). Participants in the 'without' group considered the study conclusion to be more valid than those in the 'with' group (mean difference: 0.97, 95% CI 0.59 to 1.36, P<0.001).

CONCLUSION

The overstatements in abstract conclusions did not significantly influence the primary care physicians' evaluations of the intervention effect when necessary information about the primary outcomes was distinctly reported.

TRIAL REGISTRATION NUMBER

UMIN000025317; Pre-results.

Barriers and facilitators to the implementation of evidence-based practice by pediatric surgeons

BACKGROUND/PURPOSE

Evidence-based practice (EBP) has been identified as a foundation of mainstream medical practice, yet pediatric surgery has been slow in the acceptance and implementation of EBP.

METHODS

Semi-structured interviews of 14 pediatric surgeons were conducted to determine barriers and facilitators to EBP. Resulting data were analyzed using a systematic 3-step approached of coding, generation of specific beliefs, and identification of domains relevant to practice change.

RESULTS

Six domains were identified as relevant to changing pediatric surgeons' use of evidence in practice: environmental context and resources, goals, knowledge, skills, social influence, and social/professional role and identity. Important barriers to EBP implementation included time constrains and resource limitations, the general poor quality of evidence in pediatric surgery, a lack of required skills, and a culture that continues to rely on an apprenticeship style of teaching. Facilitators include working in a research hospital, and having a local champion/ peers that support EBP implementation. There were conflicting thoughts as to whether working as a group facilitated or impeded EBP.

CONCLUSIONS

Pediatric surgeons' use of research evidence in practice is influenced by a number of domains. These results may be used to inform the design of behavior change interventions intended to encourage EBP implementation.

LEVELS OF EVIDENCE

Level V.

The Capabilities of Nurses for Complementary and Traditional Medicine Integration in Africa

OBJECTIVE

Despite the political commitment of national governments and collaborative efforts by the World Health Organization (WHO) toward the actualization of intercultural healthcare system over the past decades, sub-Saharan African countries feature medical cohabitation rather than a truly integrated medical system. This hospital-based cross-sectional study analyzed the capabilities of nurses for complementary and traditional medicine (CTM) integration in Africa.

METHOD

Practicing nurses (n = 210) were recruited to respond to the CTM Health Belief Questionnaire (CHBQ) in December 2016. Normality of data was evaluated using Kolmogorov-Smirnov statistic with a Lilliefors significance correction. The authors assessed the relationship among nurses' knowledge, personal use, and clinical practice of CTM, using Spearman's Rank Order Correlation (rho). The differences and associations in continuous and categorical baseline variables were determined with Mann-Whitney U test/Kruskal-Wallis H test and Pearson's Chi-square test, respectively, at p < 0.05 as statistically significant.

RESULTS

The overall mean score of nurses' knowledge of CTM therapies was 38 (interquartile range [IQR] 16). This low CTM-related knowledge reflected in the poor mean performance score of 30 (IQR 17) and 22 (IQR 6) for personal use and clinical practice of CTM, respectively, among nurses. Nurses, therefore, lacked the confidence to recommend CTM therapies to patients. Yet, nurses exhibited a high positive attitude to CTM (72.7 ± 12.5). In addition to significant associations among CTM-related knowledge, education (p = 0.023), and religion (p < 0.001), the study found a positive and statistically significant correlation among CTM-related knowledge, personal use (r = 0.556, p < 0.001), and professional practice of CTM (r = 0.349, p < 0.001).

CONCLUSION

Given their substantial role in the primary and public healthcare system, improving nurses' knowledge of CTM through evidence-based nursing education and training remains the surest way to achieve appropriate CTM integration in Africa as outlined in the WHO Traditional Medicine Strategy 2014-2023.

Good intentions getting out of hand - is there a future for health care guidelines?

To date, the focus of research on guidelines has been directed toward professionals, and hospitals have merely served as the context. Little research has been performed on the dilemmas of guideline adherence in hospitals, as a setting in which multiple professional guidelines have to be implemented simultaneously; also, it is still unclear which clinical guidelines have to be aligned with other external demands, such as rules, regulations, standards, indicators, norms, and so on. Hence, different ways of studying the issue of guideline implementation are called for.

Barriers to the conduct and application of research in complementary and alternative medicine: a systematic review

BACKGROUND

The popularity of Complementary and alternative medicine (CAM) has grown considerably over the past few decades. This has been accompanied by increasing public pressure for CAM to be evidence-based. Notwithstanding, the conduct and application of research in CAM faces a number of obstacles. No systematic review has mapped these barriers to date. Therefore, this systematic literature review aimed to explore, identify and map the barriers to the conduct and application of research in CAM.

METHODS

Systematic searching of MEDLINE, Embase, AMED, CINAHL, The Cochrane library, Google scholar and Google was conducted between February and June 2016 for pertinent publications. Pearling (secondary searching) of retrieved publications was also undertaken. Literature published only in English were included; however, no year limit was placed for searching. Two critical appraisal tools were used to critically appraise descriptive studies and opinion publications.

RESULTS

A total of 21 eligible publications were included in this review; this comprised of eight primary research articles and thirteen opinion publications. A critical appraisal process found two categories of good quality publications while recognising their limitations in terms of descriptive and opinion publications. The synthesised data from the selected publications about the barriers to the conduct and application of research within CAM were captured within two broad components, namely capacity and culture. Capacity encompassed elements such as access, competency, bias, incentives and time. Encompassed within culture were elements relating to the values and complex system of CAM.

CONCLUSIONS

Multiple barriers exist for the conduct and application of research in CAM. Given the growing popularity of these therapies, it is essential that the evidence base underpinning CAM also continues to expand. Without overt recognition of these barriers, enabling strategies cannot be applied. By addressing these barriers, CAM professions will be able to develop a critical mass and a well-coordinated research effort to assist the integration of evidence - based practice in CAM.