Barriers to GPs' use of evidence-based medicine: a systematic review

BACKGROUND

GPs report various barriers to the use and practice of evidence-based medicine (EBM). A review of research on these barriers may help solve problems regarding the uptake of evidence in clinical outpatient practice.

AIM

To determine the barriers encountered by GPs in the practice of EBM and to come up with solutions to the barriers identified.

DESIGN

A systematic review of the literature.

METHOD

The following databases were searched: MEDLINE (PubMed), Embase, CINAHL, ERIC, and the Cochrane Library, until February 2011. Primary studies (all methods, all languages) that explore the barriers that GPs encounter in the practice of EBM were included.

RESULTS

A total of 14 700 articles were identified, of which 22 fulfilled all inclusion criteria. Of the latter, nine concerned qualitative, 12 concerned quantitative, and one concerned both qualitative and quantitative research methods. The barriers described in the articles cover the categories: evidence (including the accompanying EBM steps), the GP's preferences (experience, expertise, education), and the patient's preferences. The particular GP setting also has important barriers to the use of EBM. Barriers found in this review, among others, include lack of time, EBM skills, and available evidence; patient-related factors; and the attitude of the GP.

CONCLUSION

Various barriers are encountered when using EBM in GP practice. Interventions that help GPs to overcome these barriers are needed, both within EBM education and in clinical practice.

Uptake of guidelines to avoid and report exposure to blood and body fluids

BACKGROUND

Mucocutaneous and percutaneous exposure to blood and body fluids (inoculation injury) are major risk factors for occupational acquisition of bloodborne infection in health care professionals. Compliance with prescribed 'universal precautions' during exposure-prone procedures has been shown to reduce the risk of acquiring bloodborne viral infection. In addition, reporting such exposures facilitates prophylaxis.

AIM

The aim of this paper is to report a study to identify strategies to minimize professionals' risks of acquiring bloodborne infections during exposure-prone procedures.

METHOD

All surgeons, theatre nurses who scrub for surgery and midwives employed in general operating theatres and delivery suites within one UK National Health Service trust (n = 276) were surveyed by postal questionnaire. Data were analysed using univariate and bivariate techniques in SPSS version 10. Content analysis was undertaken on the one open-ended question.

FINDINGS

The response rate was 72.5% (200/276). Only 1.5% (3/200) of respondents adopted universal precautions for all patients irrespective of whether their bloodborne viral status was known. On average, only half the recommended theatre-specific precautions were always adopted (mean 3.725/7, SD = 1.385). Most respondents (63.3%) admitted making judgements related to nationality, lifestyle or sexual orientation when making decisions about protective clothing. Many respondents (74%, 145/196) reported sustaining an inoculation injury in the 10 years prior to the study. However, under-reporting of injuries was common, and 32.4% (47/145) admitted failing to report injuries. Guideline adherence was influenced by profession, but not by time since qualification.

CONCLUSIONS

The findings suggest that strategies must be developed to improve compliance with universal precautions and reporting guidelines by all health care professionals. The extent of, and reasons for, non-compliance with both local and national guidelines remain relatively unexplored.

Balancing cost-effectiveness with quality in tissue viability

The 21st century has seen an increase in the importance placed on the skills of healthcare practitioners. They now need to be able to demonstrate cost-effectiveness and balance it with quality in the delivery of care in the NHS. This emphasis is driven largely by the emergence of initiatives such as evidence-based practice, clinical governance and cost-effectiveness evaluations. The pressure to demonstrate cost-effective quality practices is becoming more and more prominent in the NHS. This article will discuss the practicalities and implications these pressures have on tissue viability and wound care providers.

Clinicians' attitudes to clinical practice guidelines: a systematic review

OBJECTIVE

To systematically review surveys of clinicians' attitudes to clinical practice guidelines.

DATA SOURCES

MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.

STUDY SELECTION

We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.

RESULTS

Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%-75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%-83%), good educational tools (71%; 63%-79%) and intended to improve quality (70%; 60%-80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%-36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%-47%), would increase litigation (41%; 32%-49%) and were intended to cut healthcare costs (52.8%; 39%-66%).

CONCLUSIONS

Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

Healthcare practitioners' perceptions of clinical guidelines

This article gives an update on developments in the field of clinical guidelines with particular reference to guidelines issued by the General Medical Council and the Clinical Negligence Scheme for Trusts. It also focuses on a recent academic study on healthcare professionals' perceptions of clinical guidelines (Cotton and Sullivan, 1999) and introduces the National Guideline Clearing House which is based in the USA.