Evidence-based medicine in primary care: qualitative study of family physicians

Self-perceived knowledge, attitude, and practice of evidence-based medicine before and after training among healthcare workers in Taizhou, China

BACKGROUND

Evidence-based medicine (EBM) is the combination of the best research evidence with our clinical expertise, specific situations, and the unique values of our patients. It is essential to evaluate the effectiveness of EBM training for healthcare workers (HCWs).

OBJECTIVES

This study aims to assess the impact of EBM training on HCWs' knowledge, attitude, and practice (KAP) related to EBM.

METHODS

A self-reported online survey was carried out to investigate KAP related to EBM among HCWs at a tertiary hospital in Taizhou, China. HCWs participated in EBM training on 9 and 10 September 2023. The questionnaire survey was conducted to understand KAP related to EBM before and after the training, and to compare and analyze the results before and after the training. The R software (version 4.1.0) was used to analyze data.

RESULTS

Sixty-four HCWs completed the survey with a response rate of 52.5% (64/122). The overall average scores of KAP related to EBM before training were 55.3, 63.0, and 34.5, respectively, and 56.9, 66.5, and 34.7 were the scores of KAP after training. HCWs' scores of knowledge (P = 0.033) and attitude (P < 0.001) related to EBM improved significantly after the training.

CONCLUSION

This study implied that EBM training may improve the knowledge and attitude of HCWs, and its teaching effect is considerable.

Translation and cross-cultural adaptation of Persian version of Evidence Based Medicine Questionnaire (EBMQ) in postgraduate medical students in Iran

BACKGROUND

Evidence Based Medicine Questionnaire (EBMQ) was developed to assess the knowledge, practice and barriers towards the implementation of Evidence-Based Medicine (EBM). This study aimed to translate, cross-culturally adapt and psychometrically validate the Persian version of EBMQ.

METHODS

This was an analytical cross sectional study. The EBMQ underwent translation and cross-cultural adaptation following best practices. Face validity was assessed by a panel of five experts. The content validity index (CVI) and content validity ratio (CVR) were evaluated by 15 experts who were familiar with EBM. The tool's internal consistency and test-retest reliability over a 2-week period were evaluated using Cronbach's α and intra-class correlation (ICC), respectively. To assess construct validity, the questionnaire was completed by 400 medical students. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity assessment. All analyses were carried out using IBM SPSS v.24 and AMOS v.24. A significance level of 5% was considered.

RESULTS

The CVR for 40 items was higher than 0.62, and their CVI score was 1.0, indicating good content validity. The scale demonstrated acceptable internal consistency and test-retest reliability (n = 30) with an ICC of 0.909 (95% CI: 0.866 to 0.941), and an overall alpha coefficient of 0.957. The structural validity was established through exploratory factor analysis (Bartlett's test p<0.001; the Kaiser-Meyer-Olkin index = 0.862), and it was further confirmed by confirmatory factor analysis. A three-factor solution with 40 items, explaining 51.610% of the variance, exhibited the best fit indices Chi-square statistics/df = 4.23; RMSEA = 0.08; CFI = 0.95; NFI = 0.93; TLI = 0.92).

CONCLUSION

The Persian version of the EBMQ was a reliable and valid tool that could be utilized to assess the knowledge, practice and barriers of EBM for physicians in Persian language countries.

The voice of the profession: how the ethical demand is professionally refracted in the work of general practitioners

BACKGROUND

Among the myriad voices advocating diverging ideas of what general practice ought to be, none seem to adequately capture its ethical core. There is a paucity of attempts to integrate moral theory with empirical accounts of the embodied moral knowledge of GPs in order to inform a general normative theory of good general practice. In this article, we present an empirically grounded model of the professional morality of GPs, and discuss its implications in relation to ethical theories to see whether it might be sustainable as a general practice ethic.

METHODS

We observed and interviewed sixteen GPs and GP residents working in health care centres in four Swedish regions between 2015-2017. In keeping with Straussian Grounded Theory, sampling was initially purposeful and later theoretically guided, and data generation, analysis and theoretical integration proceeded in parallel. The focal concept of this article was refined through multidimensional property supplementation.

RESULTS

The voice of the profession is one of four concepts in our emerging theory that attempt to capture various motives that affect GPs' everyday moral decisionmaking. It reflects how GPs appreciate the situation by passing three professional-moral judgments: Shall I see what is before me, or take a bird's-eye view? Shall I intervene, or stay my hand? And do I need to speak up, or should I rather shut up? By thus framing the problem, the GP narrows down the range of considerations, allowing them to focus on its morally most pertinent aspects. This process is best understood as a way of heeding Løgstrup's ethical demand. Refracted through the lens of the GP's professional understanding of life, the ethical demand gives rise to specific moral imperatives that may stand in opposition to the express wishes of the other, social norms, or the GP's self-interest.

CONCLUSIONS

The voice of the profession makes sense of how GPs frame problematic situations in moral terms. It is coherent enough to be sustainable as a general practice ethic, and might be helpful in explaining why ethical decisions that GPs intuitively understand as justified, but for which social support is lacking, can nevertheless be legitimate.

Integrating patient values and preferences in healthcare: a systematic review of qualitative evidence

OBJECTIVES

To identify and thematically analyse how healthcare professionals (HCPs) integrate patient values and preferences ('values integration') in primary care for adults with non-communicable diseases (NCDs).

DESIGN

Systematic review and meta-aggregation methods were used for extraction, synthesis and analysis of qualitative evidence.

DATA SOURCES

Relevant records were sourced using keywords to search 12 databases (ASSIA, CINAHL, DARE, EMBASE, ERIC, Google Scholar, GreyLit, Ovid-MEDLINE, PsycINFO, PubMed-MEDLINE, Scopus and Web of Science).

ELIGIBILITY CRITERIA

Records needed to be published between 2000 and 2020 and report qualitative methods and findings in English involving HCP participants regarding primary care for adult patients.

DATA EXTRACTION AND SYNTHESIS

Relevant data including participant quotations, authors' observations, interpretations and conclusions were extracted, synthesised and analysed in a phased approach using a modified version of the Joanna Briggs Institute (JBI) Data Extraction Tool, as well as EPPI Reviewer and NVivo software. The JBI Critical Appraisal Checklist for Qualitative Research was used to assess methodological quality of included records.

RESULTS

Thirty-one records involving >1032 HCP participants and 1823 HCP-patient encounters were reviewed. Findings included 143 approaches to values integration in clinical care, thematically analysed and synthesised into four themes: (1) approaches of concern; (2) approaches of competence; (3) approaches of communication and (4) approaches of congruence. Confidence in the quality of included records was deemed high.

CONCLUSIONS

HCPs incorporate patient values and preferences in healthcare through a variety of approaches including showing concern for the patient as a person, demonstrating competence at managing diseases, communicating with patients as partners and tailoring, adjusting and balancing overall care. Themes in this review provide a novel framework for understanding and addressing values integration in clinical care and provide useful insights for policymakers, educators and practitioners.

PROSPERO REGISTRATION NUMBER

CRD42020166002.

Understanding Primary Care Physician Vaccination Behaviour: A Systematic Review

BACKGROUND

Vaccine hesitancy decreases adult vaccination coverage and has been recognized by WHO as a major health threat. Primary care physicians (PCP) play a key role in vaccination by giving vaccine counselling to their patients. The aim of this systematic review is to identify the knowledge, beliefs, attitudes and barriers (KBAB) associated with own vaccination and patient recommendation in primary care physicians.

METHODS

MEDLINE/PubMed, EMBASE and Cochrane Library databases were used to search and identify relevant studies based on their title and abstract. In the next step, the full text of each previously selected article was read for eligibility. Articles were selected by two independent reviewers and data extraction was performed using tables. The following information was extracted: methodological characteristics, demographic factors, professional characteristics, and intrinsic or extrinsic factors influencing vaccination or recommendation.

RESULTS

Our search yielded 41 eligible papers, data-sources, previous practices, belief in the effectiveness or safety of the vaccine, perceived risk, and trust in health authorities were all shown to be related to own vaccination and patient recommendation.

CONCLUSION

Internet is the main source of information for PCP related to vaccine hesitancy. It is therefore essential to increase the presence and access to pro-vaccination content in this area. In addition, involving PCP in the establishment of vaccination recommendations could improve their credibility in the institutions. On the other hand, training in communication skills and establishing reminder systems could reflect higher vaccination coverage among their patients.

The voice of the self: a typology of general practitioners' emotional responses to situational and contextual stressors

OBJECTIVE

To develop a comprehensive typology of emotional reactions associated with stress among general practitioners (GPs), grounded in their own experiences.

DESIGN

Data was generated using observations and unstructured interviews, using Straussian grounded theory as the overarching methodology. The typology was built using multidimensional property supplementation.

SETTING

Eleven health care centres in urban and rural communities in four Swedish regions.

SUBJECTS

Sixteen GPs and GP residents.

MAIN OUTCOME MEASURES

Characteristics of GPs' emotional reactions in everyday work situations.

RESULTS

Accounts of negative emotions connected to stress revealed four principal personal needs of the GP: trust, efficacy, understanding, and knowledge. Simultaneous threats to more than one of these needs invariably increased the level of tension. From these more complex accounts, six second-order needs could be identified: integrity, judgment, pursuit, authority, autonomy, and competence. The most extreme encounters, in which all four principal needs were threatened, were characterised by the experience of being reduced into an assistant.

CONCLUSION

The considerable resilience of GPs may belie some of the pressures that they are facing while being far from a fail-safe defence against being diverted from purposeful and morally responsible action. Our typology distinguishes between different forms of stress that may affect how GPs carry out their work, and connects to the vast literature on GP wellness. The results of this study could be used to develop tools for self-reflection with the aim of countering the effects of stress, and are potentially relevant to future research into its causes and consequences.Key pointsWhat is known•Stress among GPs may have severe consequences for themselves and their patients, and levels of stress appear to be increasing.What this article adds•Stressful situations threaten at least one of four principal needs of the GP: trust, efficacy, understanding, and knowledge.•More complex threats increase the level of tension and bring out second-order needs: integrity, judgment, pursuit, authority, autonomy, and competence.•The wealth of literature on GP stress can be clearly understood through the lens of our four-dimensional typology.

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.

How does the British Soft Drink Association respond to media research reporting on the health consequences of sugary drinks?

Background

Sugar-sweetened beverages (SSBs) are the leading global source of added sugar intake and their consumption is associated with negative health outcomes, such as diabetes, cancers, cardiovascular diseases, and overall mortality. Despite consensus within the public health community about the need to reduce sugar intake, the non-alcoholic beverage industry engages in efforts to publicly undermine the evidence base surrounding the harmful effects of SSBs. There has been limited investigation of how SSB industry actors engage in public debates to challenge public health research and policy on SSBs. To address this gap, we thematically analyze the public comments and press releases of the British Soft Drinks Association (BSDA) since May 2014.

Results

A total of 175 news articles and 7 press releases were identified where the BSDA commented upon new SSB research in public settings. In these comments, four strategies were observed to undermine new research. First, the BSDA challenged study rigour and research design (n = 150). They challenged the policy implications of research by stating observational studies do not demonstrate causation, refuted data sources, questioned researcher motivations, and claimed research design did not account for confounding factors. Second, the BSDA positioned themselves as an altruistic public health partner (n = 52) intent on improving population-level nutrition citing their voluntary industry commitments. Third, the BSDA promoted concepts of safety that align with industry interests (n = 47). Lastly, the BSDA argued that the lifestyle of individual consumers should be the focus of public health interventions rather than the industry (n = 61).

Conclusion

The findings illustrate the BSDA reliance on arguments of causation to discredit research and avoid policy interventions. Given the attention by the BSDA regarding the purported lack of evidence of causation between SSBs and non-communicable diseases, it is imperative that members of the public health community try to educate policy makers about (a) the complex nature of causation; (b) that evidence in favour of public health interventions cannot, and do not, solely rely on causation studies; and (c) that public health must sometimes abide by the precautionary principle in instituting interventions.

The unresolved role of the neurologist in providing dietary advice to people with multiple sclerosis

BACKGROUND

People with MS often make dietary changes after diagnosis with the aim of slowing disease progression. Although people with MS commonly use the internet for information on diet and MS, neurologists are their preferred source of information. However, little is known about what dietary advice is provided by neurologists.

OBJECTIVES

To explore the perceptions of neurologists about diet and MS, and to identify the type of dietary advice they provide to their patients with MS.

METHODS

In this exploratory qualitative study, 11 semi-structured interviews were conducted with neurologists in Western Australia. Audio files were transcribed verbatim, and transcripts were thematically analysed using a general inductive approach.

RESULTS

Four themes emerged: 1) juggling the evidence on the role of diet in MS; 2) acknowledging the risks and benefits of specific diets; 3) distancing from the diet 'gurus'; and 4) the unresolved role of the neurologist in providing dietary advice.

CONCLUSION

Neurologists could meet their patients' expectations by providing evidence-based dietary advice, such as promoting the benefits of diets that adhere to national dietary guidelines, and being prepared to explain potential risks of restrictive diets. Information about healthy eating needs to be targeted to people with MS.

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.

Perceptions, behaviours, barriers and needs of evidence-based medicine in primary care in Beijing: a qualitative study

Background

Evidence-based medicine (EBM) is gradually being recognized worldwide as an important clinical skill and plays an important role in health care. Although the concept has successfully spread in the health care field, EBM still has not been widely incorporated into clinical decisions in primary care due to potential barriers. This study aimed to explore the views, experiences and obstacles of general practitioners (GPs) regarding the use EBM in their daily clinical practices in Beijing.

Methods

We performed a qualitative study with GP focus groups. Thirty-two GPs working in 26 community health service centres in 7 districts in Beijing were recruited. Four focus group sessions with 32 GPs were conducted in a meeting room at the Capital Medical University from January to February in 2018 in Beijing. All sessions were audio-recorded, transcribed and analysed for themes using an inductive content analysis approach.

Results

GPs believed that EBM could help them enhance the quality of their clinical practice. The most common EBM behaviour of GPs was making clinical decisions according to guidelines. The barriers that limited the implementation of EBM were patients’ poor compliance, lack of time, lack of resources, inadequate skills or knowledge, and guideline production problems. The first need for GPs was to participate in training to enhance their skills in practising EBM.

Conclusions

To practise EBM in general practice, integrated interventions of different levels need to be developed, including enhancing GPs’ communication skill and professional competency, training GPs on the implementation of EBM, employing more staff to reduce GPs’ workloads, providing adequate resource support, and developing evidence-based clinical guidelines for GPs.

Nationwide Epidemiological Study of Knowledge, Attitudes, and Practices Study of Greek General Practitioners Related to Screening

Background:

We aimed to assess general practitioners’ (GPs) knowledge, attitudes, and practices (KAPs) toward screening recommendation guidelines of the United States Preventive Services Task Force (USPSTF).

Methods:

The survey was conducted during a 6-month period in a stratified random sample of GPs, drawn from a national database of GPs in Greece. Participants were queried about their knowledge, attitudes, and self-reported practice patterns regarding screening in a primary care setting. Sociodemographic characteristics associated with vague screening practicing were identified using multivariable logistic regression models.

Results:

A total of 299 participants agreed and underwent telephonic survey (response rate: 78.2%). GPs agreed on the key role of population-based screening in improving patient care, and nine out of ten reported that their performance would be improved with the adoption of computer-based support systems in clinical practice. GPs, older than 50 years of age, those who those practicing for more than 15 years and GPs working in private sector, were less likely to comply with screening recommendations. Latent class analysis revealed that male physicians and those working in public sector were more likely to comply with USPSTF recommendations.

Conclusions:

Our findings highlight the need of educational intervention programs for GPs in order to promote the implementation of national evidence-based screening recommendation statements in clinical practice.

Clinical Physicians' Attitudes towards Evidence-Based Medicine (EBM) and Their Evidence-Based Practice (EBP) in Wuhan, China

Objective: Numerous studies have proved the importance of Evidence-Based Medicine (EBM) in daily clinical practice, however, clinicians’ attitudes play an important role in determining its implementation. The objective of this study was to investigate Chinese clinical physicians’ perception of and attitude towards EBM and their Evidence-Based Practice (EBP) as well as the barriers towards EBP. Methods: Using a cross-sectional design, self-response questionnaires were distributed to clinical physicians (internal medicine and surgery departments) across three tertiary hospitals in Wuhan, China. Results: In total, 131 out of 195 (67.2%) physicians completed and returned the questionnaire. A total of 64.9% of the physicians either knew moderately or a lot about EBM. The mean score of physicians’ attitude toward EBM was 2.35 ± 0.35, and that of their EBP skill/ competency was 1.51 ± 0.56 (on 0–3 Likert scale). In total, 76.0% of physicians often or sometimes applied EBM in routine daily practice. The largest barrier preventing implementation was the varying individual differences in diseases (61.0%), followed by a lack of investment from the hospital/department (39.8%), and a lack of patient cooperation (37.4%). Chinese physicians in tertiary hospitals possessed expressed positive attitudes towards EBM; however, they only retained a moderate level of clinical evidence competency. Both an individual factor (personal interest) and organizational factors (workload, hospital requirement) had an effect on physicians’ attitudes and their EBP skills. Management and organizational efforts, in addition to time dedicated for EBP projects could help reduce barriers that prevent EBP.

Artificial Intelligence and the Implementation Challenge

Background

Applications of artificial intelligence (AI) in health care have garnered much attention in recent years, but the implementation issues posed by AI have not been substantially addressed.

Objective

In this paper, we have focused on machine learning (ML) as a form of AI and have provided a framework for thinking about use cases of ML in health care. We have structured our discussion of challenges in the implementation of ML in comparison with other technologies using the framework of Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies (NASSS).

Methods

After providing an overview of AI technology, we describe use cases of ML as falling into the categories of decision support and automation. We suggest these use cases apply to clinical, operational, and epidemiological tasks and that the primary function of ML in health care in the near term will be decision support. We then outline unique implementation issues posed by ML initiatives in the categories addressed by the NASSS framework, specifically including meaningful decision support, explainability, privacy, consent, algorithmic bias, security, scalability, the role of corporations, and the changing nature of health care work.

Results

Ultimately, we suggest that the future of ML in health care remains positive but uncertain, as support from patients, the public, and a wide range of health care stakeholders is necessary to enable its meaningful implementation.

Conclusions

If the implementation science community is to facilitate the adoption of ML in ways that stand to generate widespread benefits, the issues raised in this paper will require substantial attention in the coming years.

Clinician experiences of healthy lifestyle promotion and perceptions of digital interventions as complementary tools for lifestyle behavior change in primary care

BACKGROUND

Evidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention.

METHODS

Focus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving naïve understanding, structural analysis and comprehensive understanding.

RESULTS

Two major themes captured clinicians' perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one's perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines.

CONCLUSIONS

In efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors.

Sources of clinical information used in HIV care and treatment: Are providers' choices related to their demographic and practice characteristics?

HIV medical care providers need a wide range of evidence-based clinical information resources to manage their patients' health. We determined whether providers' choice of information sources for HIV care and treatment are associated with their demographic and medical practice characteristics. Data used for this study were obtained from a probability sample of HIV medical care providers in 13 outpatient HIV facilities in Houston/Harris County, Texas, surveyed between June and September 2009. The mean number of information sources used by HIV medical care providers for HIV care and treatment was 5.83 (95% confidence interval: 4.90-6.75). Antiretroviral therapy guidelines (95.6%), medical journals and textbooks (82.6%), and Internet sources (69.5%) were ranked first, second, and third as sources of clinical information. At least one of the providers' demographic or medical practice characteristics was significantly (p ⩽ 0.05) associated with six of the clinical information sources. Integration of these information resources into clinicians' workflow may enhance efficiency of HIV care and treatment and facilitate improved patients' care and health outcomes.

Development and validation of the Evidence Based Medicine Questionnaire (EBMQ) to assess doctors' knowledge, practice and barriers regarding the implementation of evidence-based medicine in primary care

Background

Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients’ values, which then informs clinical decision making. However, there is a lack of validated instruments to assess the knowledge, practice and barriers of primary care physicians in the implementation of EBM. This study aimed to develop and validate an Evidence-Based Medicine Questionnaire (EBMQ) in Malaysia.

Methods

The EBMQ was developed based on a qualitative study, literature review and an expert panel. Face and content validity was verified by the expert panel and piloted among 10 participants. Primary care physicians with or without EBM training who could understand English were recruited from December 2015 to January 2016. The EBMQ was administered at baseline and two weeks later. A higher score indicates better knowledge, better practice of EBM and less barriers towards the implementation of EBM. We hypothesized that the EBMQ would have three domains: knowledge, practice and barriers.

Results

The final version of the EBMQ consists of 80 items: 62 items were measured on a nominal scale, 22 items were measured on a 5 point Likert-scale. Flesch reading ease was 61.2. A total of 343 participants were approached; of whom 320 agreed to participate (response rate = 93.2%). Factor analysis revealed that the EBMQ had eight domains after 13 items were removed: “EBM websites”, “evidence-based journals”, “types of studies”, “terms related to EBM”, “practice”, “access”, “patient preferences” and “support”. Cronbach alpha for the overall EBMQ was 0.909, whilst the Cronbach alpha for the individual domain ranged from 0.657–0.940. The EBMQ was able to discriminate between doctors with and without EBM training for 24 out of 42 items. At test-retest, kappa values ranged from 0.155 to 0.620.

Conclusions

The EBMQ was found to be a valid and reliable instrument to assess the knowledge, practice and barriers towards the implementation of EBM among primary care physicians in Malaysia.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0779-5) contains supplementary material, which is available to authorized users.

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.

A real-world approach to Evidence-Based Medicine in general practice: a competency framework derived from a systematic review and Delphi process

BACKGROUND

Evidence-Based Medicine (EBM) skills have been included in general practice curricula and competency frameworks. However, GPs experience numerous barriers to developing and maintaining EBM skills, and some GPs feel the EBM movement misunderstands, and threatens their traditional role. We therefore need a new approach that acknowledges the constraints encountered in real-world general practice. The aim of this study was to synthesise from empirical research a real-world EBM competency framework for general practice, which could be applied in training, in the individual pursuit of continuing professional development, and in routine care. We sought to integrate evidence from the literature with evidence derived from the opinions of experts in the fields of general practice and EBM.

METHODS

We synthesised two sets of themes describing the meaning of EBM in general practice. One set of themes was derived from a mixed-methods systematic review of the literature; the other set was derived from the further development of those themes using a Delphi process among a panel of EBM and general practice experts. From these two sets of themes we constructed a real-world EBM competency framework for general practice.

RESULTS

A simple competency framework was constructed, that acknowledges the constraints of real-world general practice: (1) mindfulness - in one's approach towards EBM itself, and to the influences on decision-making; (2) pragmatism - in one's approach to finding and evaluating evidence; and (3) knowledge of the patient - as the most useful resource in effective communication of evidence. We present a clinical scenario to illustrate how a GP might demonstrate these competencies in their routine daily work.

CONCLUSION

We have proposed a real-world EBM competency framework for general practice, derived from empirical research, which acknowledges the constraints encountered in modern general practice. Further validation of these competencies is required, both as an educational resource and as a strategy for actual practice.

Who's afraid of EBM? Medical professionalism from the perspective of evidence-based medicine

Evidence-based medicine (EBM) and medical professionalism are two prominent notions in current medical debates. However, proponents of professionalism fear a restriction in doctors' freedom to make their best decisions for individual patients caused by the influence of EBM and highly standardised decision procedures. The challenge which EBM allegedly poses to physicians' discretion forms the starting point for an analysis of the relationship between professionalism, as an inherent value system of medical practice, and EBM, as an approach to optimise the decision-making for individual patients. The analysis starts with a brief conceptual clarification of the ambiguous term "professionalism". It then focuses on three key aspects of medical professionalism which may come into conflict with the basic tenets of EBM. The potential tensions between (a) professional autonomy and clinical practice guidelines, (b) individualised care and standardisation, and (c) esoteric authority and public accountability are analysed and a suggestion for reconcilement regarding each point is made. The article closes with a summary on how a better reflection on medical professionalism may help towards a fuller understanding of EBM and vice versa.

Systems 1 and 2 thinking processes and cognitive reflection testing in medical students

BACKGROUND

Diagnostic decision-making is made through a combination of Systems 1 (intuition or pattern-recognition) and Systems 2 (analytic) thinking. The purpose of this study was to use the Cognitive Reflection Test (CRT) to evaluate and compare the level of Systems 1 and 2 thinking among medical students in pre-clinical and clinical programs.

METHODS

The CRT is a three-question test designed to measure the ability of respondents to activate metacognitive processes and switch to System 2 (analytic) thinking where System 1 (intuitive) thinking would lead them astray. Each CRT question has a correct analytical (System 2) answer and an incorrect intuitive (System 1) answer. A group of medical students in Years 2 & 3 (pre-clinical) and Years 4 (in clinical practice) of a 5-year medical degree were studied.

RESULTS

Ten percent (13/128) of students had the intuitive answers to the three questions (suggesting they generally relied on System 1 thinking) while almost half (44%) answered all three correctly (indicating full analytical, System 2 thinking). Only 3-13% had incorrect answers (i.e. that were neither the analytical nor the intuitive responses). Non-native English speaking students (n = 11) had a lower mean number of correct answers compared to native English speakers (n = 117: 1.0 s 2.12 respectfully: p < 0.01). As students progressed through questions 1 to 3, the percentage of correct System 2 answers increased and the percentage of intuitive answers decreased in both the pre-clinical and clinical students.

CONCLUSIONS

Up to half of the medical students demonstrated full or partial reliance on System 1 (intuitive) thinking in response to these analytical questions. While their CRT performance has no claims to make as to their future expertise as clinicians, the test may be used in helping students to understand the importance of awareness and regulation of their thinking processes in clinical practice.

Evidence-Based Practice Point-of-Care Resources: A Quantitative Evaluation of Quality, Rigor, and Content

OBJECTIVE

Clinicians and other healthcare professionals need access to summaries of evidence-based information in order to provide effective care to their patients at the point-of-care. Evidence-based practice (EBP) point-of-care resources have been developed and are available online to meet this need. This study aimed to develop a comprehensive list of available EBP point-of-care resources and evaluate their processes and policies for the development of content, in order to provide a critical analysis based upon rigor, transparency and measures of editorial quality to inform healthcare providers and promote quality improvement amongst publishers of EBP resources.

DESIGN

A comprehensive and systematic search (Pubmed, CINAHL, and Cochrane Central) was undertaken to identify available EBP point-of-care resources, defined as "web-based medical compendia specifically designed to deliver predigested, rapidly accessible, comprehensive, periodically updated, and evidence-based information (and possibly also guidance) to clinicians."

MAIN OUTCOME MEASURES

A pair of investigators independently extracted information on general characteristics, content presentation, editorial quality, evidence-based methodology, and breadth and volume.

RESULTS

Twenty-seven summary resources were identified, of which 22 met the predefined inclusion criteria for EBP point-of-care resources, and 20 could be accessed for description and assessment. Overall, the upper quartile of EBP point-of-care providers was assessed to be UpToDate, Nursing Reference Centre, Mosby's Nursing Consult, BMJ Best Practice, and JBI COnNECT+.

LINKING EVIDENCE TO ACTION

The choice of which EBP point-of-care resources are suitable for an organization is a decision that depends heavily on the unique requirements of that organization and the resources it has available. However, the results presented in this study should enable healthcare providers to make that assessment in a clear, evidence-based manner, and provide a comprehensive list of the available options.

The Information Seeking and Communication Model

Purpose

– This study investigated the application in the field of healthcare of a recently developed model of information seeking and communication. The purpose of this paper is to test the model’s validity and to identify insights that it may provide.

Design/methodology/approach

– To investigate the model’s application to information users, the findings from published literature on physicians’ information behaviour were studied. To investigate its application to information providers, interviews were carried out with staff working for the National Institute for Health and Care Excellence and with employees of pharmaceutical companies. The findings were examined using deductive content analysis.

Findings

– The findings endorse the validity of the model, with minor modifications. The model provides practical insights into the behaviour of both users and providers of information and the factors that influence them. It can be used to identify ways in which information behaviour may be positively modified in both finding and communicating healthcare information.

Originality/value

– This research demonstrates the practical value of a new model of information behaviour which was developed using insights from earlier models. In doing so it answers criticisms that research in library and information science often fails to build on previous research and that it has little practical usefulness.

Evidence-based medicine use in pharmacy practice: a cross-sectional survey

RATIONALE, AIMS AND OBJECTIVES

This study aimed to evaluate the awareness, attitude, knowledge and use of evidence-based medicine (EBM) among pharmacists in Jordan.

METHODS

A cross-sectional self-reported survey was conducted on 122 pharmacists (both hospital and community) who were asked to fill a validated structured questionnaire.

RESULTS

The participants showed a positive attitude towards EBM; more than 80% thought that EBM improves patient care, improves quick knowledge update, helps to unify the quality of care provided, is a good educational tool and a convenient source of advice. But despite this positive attitude, pharmacists showed partial understanding of the technical terms used in EBM; also they relied on their own judgment, medical representatives and standard textbooks in making their decision, resources that can no longer be considered sufficiently updated and/or evidence based. Patient overload, lack of personal time and limited access to EBM sources were the most commonly identified barrier to practicing EBM. Also this study suggest that pharmacist's experience is negatively associated with EBM knowledge score (Spearman's rho value -0.187, P-value 0.04).

CONCLUSIONS

In spite of the positive attitude towards EBM, this study showed numerous personal and institutional barriers towards implementing EBM in Jordan, which necessitate immediate action by all health care decision makers to formulate a national plan to overcome such barriers, and to further investigate the evidence that teaching, learning and daily application of EBM in practice can improve the quality of care and reduce the cost.

"My approach to this job is...one person at a time": Perceived discordance between population-level quality targets and patient-centred care

OBJECTIVE

To understand the usefulness of audit and feedback among family physicians and examine the barriers to using it to improve quality of care.

DESIGN

Qualitative study using in-depth interviews.

SETTING

Family physicians across Ontario participating in audit and feedback initiatives describing the proportion of patients meeting quality targets for chronic disease.

PARTICIPANTS

Purposive sampling was conducted to ensure variation in sex, years of experience, and baseline performance for quality metrics. All participants used electronic medical records and worked in multidisciplinary primary care practices.

METHODS

Semistructured interviews were conducted with family physicians. The interview guide and initial coding framework were adjusted iteratively in keeping with the constant comparative method. Sampling continued until saturation was reached. Interviews were analyzed using the framework approach.

MAIN FINDINGS

Participants reported that the feedback increased their awareness of gaps between ideal and actual performance. This resulted mainly in efforts to "try harder" patient by patient. Key barriers to acting upon feedback in a systematic manner included a perceived discordance between population-level quality targets and patient-centred care, as well as competing priorities at both the patient and organizational levels. Although all participants had electronic medical records, participants reported a lack of quality improvement infrastructure in their practices.

CONCLUSION

Family physicians were not highly motivated to achieve evidence-based population-level quality targets for diabetes; many competing organizational and clinical goals took priority. Additional human resources might be needed to translate data in feedback reports into systematic changes that could lead to sustained improvements in quality of care.

Would GPs advise patients with respiratory tract infections to refrain from exercise, stay indoors or stay in bed? Survey of GPs in Poland and Norway

BACKGROUND

For patients with respiratory tract infections evidence regarding bed rest, staying indoors and refraining from exercise is sparse.

OBJECTIVES

To explore how general practitioners (GPs) in Poland and Norway would advise such patients.

METHODS

Convenience samples of GPs in Poland (n = 216) and Norway (n = 171) read four vignettes in which patients presented symptoms consistent with pneumonia, sinusitis, common cold and exacerbation of chronic obstructive pulmonary disease (COPD), respectively. For each vignette, GPs were asked whether they would recommend staying indoors, staying in bed and refraining from exercise, and if so, for how many days.

RESULTS

For each vignette, the proportions of GPs recommending the patient to stay indoors in Poland versus Norway were 98% versus 72% (pneumonia), 92% versus 26% (sinusitis), 87% versus 9% (common cold) and 92% versus 39% (exacerbation of COPD). In regression analysis adjusted relative risks (95% CI) for recommending the patient to stay indoors in Poland versus Norway was 1.4 (1.2-1.5), 3.7 (2.8-4.8), 10.6 (6.3-17.7) and 2.5 (2.0-3.1), respectively. Among those who would recommend the patient to stay indoors, mean durations were 8.1, 6.6, 5.1 and 6.7 days in Poland versus 3.2, 2.8, 2.6 and 4.1 days in Norway, respectively. Polish GPs were also more likely to recommend staying in bed and refraining from exercise, and for a longer time, than their Norwegian colleagues.

CONCLUSION

GPs in Poland were more likely to recommend bed rest, staying indoors and refraining from exercise. This suggests that they perceived the cases as more serious than their Norwegian colleagues.

Evaluating factors affecting the implementation of evidence based medicine in primary healthcare centers in Dubai

OBJECTIVES

To assess the current evidence based medicine (EBM) knowledge, attitude and perceptions of physicians at Dubai Primary Health Care Sector (PHCS). Further to evaluate barrier and facilitator factors toward implementing the EBM practice.

METHODOLOGY

A cross-sectional study, at Dubai PHCS, UAE between June and August 2010. The survey was composed of two phases. The first phase was a self administrated questionnaire employed for data collection and the second phase was qualitative method, which was in the form of individual interviews. Statistical Package for Social Sciences (SPSS) was used for data analysis.

RESULTS

In total 48 participants responded to the survey questionnaire and 13 responded to individual interviews. The response rate was 70.0%. Mean age was 42.18 (SD 10.46). The majority were females (64.6%). The physicians who attended EBM courses reported 70.30% using EBM and showed statistical significance (p = 0.002) from those who did not attend the EBM courses. 65.0% believe that 50-75% of the patients are capable of participating in clinical decision while 71.8% disagreed that the concept of EBM is not applicable to their culture. In addition they showed significance (p = 0.03) between physician beliefs with regard to patient capacity to take decision. About 67.0% of the family physicians were knowledgeable and followed systematic review as the strongest evidence. They had no access to the EBM resources (37.0%) and had no time to practice the EBM (38.0%). Nearly 40.0% interviewees reported lack of encouragement to attend EBM courses. EBM activities (22.0%) and active audit (18.0%) were top rated facilitating factors.

CONCLUSIONS

EBM is not fully utilized by indefinite physicians in the Dubai PHC sector. Factors associated with non-utilization of EBM in the PHCS are lack of encouragement to attend EBM courses, senior physicians resist adoption of EBM, lack of time and insufficient dissemination process for implementing the clinical guideline.

Evidence-based practice in a multiprofessional context

BACKGROUND

Healthcare today is a complex system with increasing needs of specific knowledge of evaluation of research and implementation into clinical practice. A critical issue is that we all apply evidence-based practice (EBP) with standardised methods and continuing and systematic improvements. EBP includes both scientific and critical assessed experience-based knowledge. For the individual, this means applying evidence-based knowledge to a specific situation, and for the organisation, it means catering for a systematic critical review and evaluation and compiling research into guidelines and programmes. In 2009, the County Council of Jönköping had approximately 335,000 inhabitants and the healthcare organisation had more than 10,000 employees. As the County Council actively promotes clinical improvement, it is interesting to explore how healthcare employees think about and act upon EBP. The aim of this survey was therefore to describe factors that facilitate or hinder the application of EBP in the clinical context.

METHOD

A quantitative study was performed with a questionnaire to healthcare staff employed in the County Council of Jönköping in 2009. The questionnaire consisted of questions concerning which factors are experienced to affect the development of evidence-based healthcare. There were 59 open and closed questions, divided into the following areas: • Sources of knowledge used in practice • Barriers to finding and evaluating research reports and guidelines • Barriers to changing practice on the basis of best evidence • Facilitating factors for changing practice on the basis of best evidence • Experience in finding, evaluating and using different sources of evidence. The participants were selected using the county council's staff database and included medical, caring and rehabilitative staff within hospitals, primary care, dentistry and laboratory medicine. The inclusion criteria were permanent employment and clinical work. Invitations were sent to 5787 persons to participate in the study and 1445 persons answered the questionnaire.

RESULTS

Knowledge used in daily clinical practice was mainly based on information about the patient, personal experience and local guidelines. Twenty per cent answered that they worked 'in the way they always had', and 11% responded that they used evidence from research as a basis for change. The participants experienced that EBP was not used enough in clinical healthcare and explained this with practical and structural barriers, which they thought should be better monitored by the organisation and directors.

CONCLUSION

Overall, the results indicate that the scientific evidence for healthcare is not used sufficiently as a base for decisions in daily practice as well as for changing practice. This is more prominent among assistant staff. As a consequence, this might affect the care of the patients in a negative way. Increased awareness of EBP and a stronger evidence-based approach are keys in the ongoing improvement work in the county. Local guidelines seem to be a way to implement knowledge. But, as the arena of activities is complex and the employees have diverse education levels, different strategies to facilitate and promote EBP are necessary.

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.

Understanding and teaching key concepts and tools of evidence-based medicine: perspectives of a clinician-researcher pharmaceutical physician

Clinical practice benefits from research to inform good decision making. Evidence-based medicine (EBM) helps physicians integrate experience and individual expertise with the best evidence. Various philosophical concepts, including "primum non nocere," are balanced to achieve this. The tools of EBM, such as number needed to treat, are easy to calculate and to use. Other valuable tools include number needed to harm, attributable risk, and likelihood of being helped or harmed. It is also important to distinguish between relative risk and absolute risk to avoid drawing the wrong conclusions. With the right teaching techniques to grab attention and encourage active participation, real examples can be used to impart practical skills that the clinician can employ in translating research findings into something that helps the individual patient.

Reducing the pain: a systematic review of postdischarge analgesia following elective orthopedic surgery

OBJECTIVE

This study aimed to determine which analgesic modalities used following discharge have the greatest efficacy in reducing postoperative pain after elective non-axial orthopedic surgery.

DESIGN AND SETTING

A systematic review was conducted using the databases CENTRAL, MEDLINE, and EMBASE, as well as clinical practice guidelines databases and trial registries. Titles and abstracts were perused by two reviewers for randomized clinical trials in English fulfilling inclusion and exclusion criteria. Quality assessments, including the Oxford Quality Score, selective reporting, and sources of funding, were also performed.

OUTCOME MEASURES

Pain intensity/relief, global patient evaluation, and use of rescue analgesia, as well as adverse events and withdrawals.

RESULTS

2,167 articles were retrieved and 23 articles were eligible for inclusion. They investigated analgesic modalities including alternative therapies (5); cyclooxygenase-2 inhibitors (3); nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) (12); opioids (2); and other pharmaceutical classes (1). Cycooxygenase-2 inhibitors and opioids demonstrated significant efficacy with minimal side effects. Most nonselective NSAIDs were effective analgesics but had a poorer side-effect profile. Alternative therapies demonstrated no significant efficacy.

CONCLUSIONS

Opioids and cyclooxygenase-2 inhibitors are effective in providing analgesia in the extended postoperative period following orthopedic surgery with a minimal side-effect profile, while nonselective NSAIDs need to be treated with caution. Homeopathy is not an effective analgesic, while acupuncture has varied evidence and effectiveness. Treatment of postoperative fatigue may also improve analgesia control. This study provides orthopedic surgeons with a basis for evidence-based prescribing of postdischarge analgesia. However, further studies to validate these results against modern reporting standards are needed.

EBM in primary care: a qualitative multicenter study in Spain

BACKGROUND

Evidence based medicine (EBM) has made a substantial impact on primary care in Spain over the last few years. However, little research has been done into family physicians (FPs)' attitudes related to EBM. The present study investigates FPs' perceptions of EBM in the primary care context.

METHODS

This study used qualitative methodology. Information was obtained from 8 focus groups composed of 67 FPs from 47 health centers in 4 autonomous regions in Spain. Intentional sampling considered participants' previous education in EBM, and their experience as tutors in family medicine or working groups' members of the Spanish Society of Family Practice. Sociological discourse analysis was used with the support of the MAXqda software. Results were validated by means of triangulation among researchers and contrast with participants.

RESULTS

Findings were grouped into three main areas: 1) The tug-of-war between the "science" of EBM and "experience" in the search for good clinical practice in primary care; 2) The development of EBM sensemaking as a reaction to contextual factors and interests; 3) The paradox of doubt and trust in the new EBM experts.The meaning of EBM was dynamically constructed within the primary care context. FPs did not consider good clinical practice was limited to the vision of science that EBM represents. Its use appeared to be conditioned by several factors that transcended the common concept of barriers. Along with concerns about its objectivity, participants showed a tendency to see EBM as the use of simplified guidelines developed by EBM experts.

CONCLUSIONS

The identification of science with EBM and its recognition as a useful but insufficient tool for the good clinical practice requires rethinking new meanings of evidence within the primary care reality. Beyond the barriers related to accessing and putting into practice the EBM, its reactive use can determine FPs' questions and EBM development in a direction not always centred on patients' needs. The questioning of experts' authority as a pillar of EBM could be challenged by the emergence of new kinds of EBM texts and experts to believe in.

When should patient intuition be taken seriously?

As a style of information processing, intuition involves implicit perceptual and cognitive processes that can be quickly and automatically executed without conscious mental will, such that people know more than they can describe. Patient intuition can influence patient and clinician decision-making and behavior. However, physicians may not always see patient intuition as credible or important, and its management in the clinical setting is poorly understood. This paper takes a step toward suggesting conditions under which patient intuition should be taken seriously. These conditions relate to the credibility or accuracy of the intuitive beliefs held by the patient, and their significance to the patient. Credibility may be increased when the intuitions of patients (1) reflect their individualized knowledge, (2) can complement the common absence of scientific evidence in managing health problems, and (3) can quickly and effectively process key information in complex cognitive tasks. Even intuitions that lack credibility can be subjectively rational and meaningful to patients, and help to shape the decisions they and clinicians make.

Are interventions recommended by pharmacists during Home Medicines Review evidence-based?

INTRODUCTION

Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence-based medicine have been investigated, the extent to which medication review recommendations are evidence-based is not known.

OBJECTIVE

To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence-based guides at the time of the review; and (2) the nature and extent of drug-related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs.

METHOD

A retrospective review of Home Medicines Review cases performed on 224 community-dwelling older people (65 years or older). The chi-squared test for categorical variables was used to compare the proportion of recommendations that were evidence-based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria.

RESULTS

Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence-based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected.

CONCLUSION

The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at-risk population.

Predictive ability of an early diagnostic guess in patients presenting with chest pain; a longitudinal descriptive study

Background

The intuitive early diagnostic guess could play an important role in reaching a final diagnosis. However, no study to date has attempted to quantify the importance of general practitioners' (GPs) ability to correctly appraise the origin of chest pain within the first minutes of an encounter.

Methods

The validation study was nested in a multicentre cohort study with a one year follow-up and included 626 successive patients who presented with chest pain and were attended by 58 GPs in Western Switzerland. The early diagnostic guess was assessed prior to a patient's history being taken by a GP and was then compared to a diagnosis of chest pain observed over the next year.

Results

Using summary measures clustered at the GP's level, the early diagnostic guess was confirmed by further investigation in 51.0% (CI 95%; 49.4% to 52.5%) of patients presenting with chest pain. The early diagnostic guess was more accurate in patients with a life threatening illness (65.4%; CI 95% 64.5% to 66.3%) and in patients who did not feel anxious (62.9%; CI 95% 62.5% to 63.3%). The predictive abilities of an early diagnostic guess were consistent among GPs.

Conclusions

The GPs early diagnostic guess was correct in one out of two patients presenting with chest pain. The probability of a correct guess was higher in patients with a life-threatening illness and in patients not feeling anxious about their pain.

[What do general practitioners think about evidenced-based medicine? A study with focus groups]

OBJECTIVE

To examine the attitudes of a sample of General Practitioners (GPs) towards Evidenced-Based Medicine (EBM) and its use and the obstacles to put into practice in Primary Care (PC).

DESIGN

Qualitative study using Focus Groups (FG).

SETTING

Primary Care in the Autonomous Community of Murcia, Spain, January-June 2007.

PARTICIPANTS

GPs with a clinical practice in PC in the Murcian Health Service.

METHOD

Two FG (with/without previous training in EBM). Using intentional sampling, 19 GPs were selected from PC professionals. The discussions were recorded on video and transcribed literally. The discussions were then, segmented, categorised and interpreted.

RESULTS

Attitudes: EBM is useful, it helps to reduce variation in clinical practice and decreases uncertainty. Great importance is given to clinical experience and the role of the Pharmaceutical Industry and the Health Administration may have in its promotion is viewed with suspicion. Use: Its use is still limited. To consult with colleagues continues to be the main source of information. Obstacles: The major difficulties identified were the limited time it has been available, lack of experience and the language.

CONCLUSIONS

Although GPs show a positive attitude towards EBM, there are still a few who recognise the use of consultation. The main limitation identified was lack of time in the clinic due to excessive pressure of care work. To increase its use, they proposed, more training activities, motivation by an appropriate process and reorganisation of their care work.

Evidence-based medicine among Jordanian family physicians: awareness, attitude, and knowledge

OBJECTIVE

To assess family practitioners' attitudes toward and awareness of evidence-based medicine (EBM).

DESIGN

A cross-sectional study from a questionnaire distributed between January and March 2007.

SETTING

Rural and urban family medicine centres throughout Jordan that are affiliated with the Ministry of Health, military centres, university medical centres, and the private sector.

PARTICIPANTS

Two hundred family physicians.

MAIN OUTCOME MEASURES

Family physicians' attitudes toward EBM; training in EBM; barriers to practising EBM; level of awareness of and access to EBM journals and databases; and knowledge and understanding of related technical terms.

RESULTS

The response rate was 70.5%. Among those who responded, 56.7% were women and 42.6% were between the ages of 40 and 49 years. More than 50% of the respondents were working in mixed urban and rural practice settings. Most of the respondents had a positive attitude toward EBM: 63.5% welcomed the concept of EBM; more than 40% used EBM in their daily practices; and 90% agreed that practising EBM improved patient care. Of the respondents, 42.6% thought that the best way to move from opinion-based medicine to EBM was through learning the skills of EBM. Fifty percent of the respondents had access to MEDLINE, while only 20.4% of them had received formal training in research and critical appraisal. Lack of personal time was the main perceived barrier to practising EBM. Participants reported a low level of awareness of some of the technical terms.

CONCLUSION

Jordanian family physicians showed eagerness to learn and implement EBM in their daily practices. Nevertheless, they need more guidance and training to ensure the correct application of EBM ideals.

Perceptions, attitudes and knowledge of evidence-based medicine in primary care in Spain: a study protocol

BACKGROUND

The philosophy of evidence-based medicine (EBM) was introduced in the early 90s as a new approach to the practice of medicine, using the best available evidence to make decisions about health care. Despite ongoing controversy, EBM has developed enormously and physicians' attitude towards it is generally positive. Nevertheless, in Spain little is known about this topic. We will therefore undertake a study to explore perceptions, attitudes and knowledge about EBM among primary care physicians.

METHODS AND DESIGN

A mixed-method study combining qualitative and quantitative designs will target family practitioners in Spain with the objective of evaluating current attitudes and perceptions about evidence-based medicine. The project will consist of two phases: a first phase running focus groups to identify perceptions and attitudes of participants, and a second phase assessing their attitudes and knowledge about EBM by means of a survey. Both phases will explore these issues in three different subgroups: family practitioners, with or without previous formal education in EBM; members of working groups that formulate healthcare recommendations; and physicians in charge of training family practice residents. Additionally, we will undertake a systematic review to identify and synthesize the available evidence on this topic.

DISCUSSION

The study will identify and gain insight into the perceived problems and barriers to the practice of evidence-based medicine among general practitioners in Spain. The project will also evaluate the main knowledge gaps and training needs, and explore how evidence-based medicine is being taught to family medicine residents, the medical practitioners of the future. Our results will aid researchers and health care planners in developing strategies to improve the practice of evidence-based medicine in our country.

A general framework for the evaluation of clinical trial quality

Flawed evaluation of clinical trial quality allows flawed trials to thrive (get funded, obtain IRB approval, get published, serve as the basis of regulatory approval, and set policy). A reasonable evaluation of clinical trial quality must recognize that any one of a large number of potential biases could by itself completely invalidate the trial results. In addition, clever new ways to distort trial results toward a favored outcome may be devised at any time. Finally, the vested financial and other interests of those conducting the experiments and publishing the reports must cast suspicion on any inadequately reported aspect of clinical trial quality. Putting these ideas together, we see that an adequate evaluation of clinical quality would need to enumerate all known biases, update this list periodically, score the trial with regard to each potential bias on a scale of 0% to 100%, offer partial credit for only that which can be substantiated, and then multiply (not add) the component scores to obtain an overall score between 0% and 100%. We will demonstrate that current evaluations fall well short of these ideals.

The role of economic evaluation in the decision-making process of family physicians: design and methods of a qualitative embedded multiple-case study

Background

A considerable amount of resource allocation decisions take place daily at the point of the clinical encounter; especially in primary care, where 80 percent of health problems are managed. Ignoring economic evaluation evidence in individual clinical decision-making may have a broad impact on the efficiency of health services. To date, almost all studies on the use of economic evaluation in decision-making used a quantitative approach, and few investigated decision-making at the clinical level. An important question is whether economic evaluations affect clinical practice. The project is an intervention research study designed to understand the role of economic evaluation in the decision-making process of family physicians (FPs). The contributions of the project will be from the perspective of Pierre Bourdieu's sociological theory.

Methods/design

A qualitative research strategy is proposed. We will conduct an embedded multiple-case study design. Ten case studies will be performed. The FPs will be the unit of analysis. The sampling strategies will be directed towards theoretical generalization. The 10 selected cases will be intended to reflect a diversity of FPs. There will be two embedded units of analysis: FPs (micro-level of analysis) and field of family medicine (macro-level of analysis). The division of the determinants of practice/behaviour into two groups, corresponding to the macro-structural level and the micro-individual level, is the basis for Bourdieu's mode of analysis. The sources of data collection for the micro-level analysis will be 10 life history interviews with FPs, documents and observational evidence. The sources of data collection for the macro-level analysis will be documents and 9 open-ended, focused interviews with key informants from medical associations and academic institutions. The analytic induction approach to data analysis will be used. A list of codes will be generated based on both the original framework and new themes introduced by the participants. We will conduct within-case and cross-case analyses of the data.

Discussion

The question of the role of economic evaluation in FPs' decision-making is of great interest to scientists, health care practitioners, managers and policy-makers, as well as to consultants, industry, and society. It is believed that the proposed research approach will make an original contribution to the development of knowledge, both empirical and theoretical.

The use of evidence-based medicine in pediatrics: past, present and future

PURPOSE OF REVIEW

Evidence-based medicine is a process that seeks to integrate the best research evidence with clinical expertise and patient values in order to optimize clinical outcomes for our patients. This article will review the benefits of and barriers to the use of evidence-based medicine in pediatrics in the twenty-first century, discuss various implementation strategies and outline the resources that pediatricians could use to increase their knowledge and skills and apply them to their clinical practice.

RECENT FINDINGS

Although physicians have generally welcomed evidence-based medicine, the benefits and limitations are often debated, and studies reveal that physicians feel that practicing evidence-based medicine could be difficult in a busy clinical practice because they lack the time, knowledge and resources. There have been many recent developments to help pediatricians overcome these barriers and to use best evidence in their practice.

SUMMARY

Pediatricians must be able to use the evidence-based medicine process to identify, access, apply and integrate new knowledge into their practice to provide high-quality care for their patients. The resources discussed in this review will help pediatricians make clinical decisions about patient care that are based on the best, most current, valid, and relevant evidence available.

Understanding the work of general practitioners: a social science perspective on the context of medical decision making in primary care

Background

The work of general practitioners (GPs) is increasingly being looked at from the perspective of the strategies and factors shaping it. This reflects the importance given to primary care services in health care system reform. However, the literature provides little insight into the medical decision-making processes in general practice. Our main objective was to better understand how organizational and environmental factors influence the work of GPs.

Methods

We interviewed 28 GPs working in contrasting organizational settings and environments. The data analysis involved using structuration theory to enrich the interpretation of empirical material.

Results

We identified four main factors that influence the practice of GPs: mode of remuneration, peer-to-peer interactions, patients' demands and the availability of other medical resources in the environment. These four conditions of action – what we call primary effects – can directly influence the performance of medical acts and time management, as well as the degree of specialization of GPs. Decisions related to each of those aspects can have a variety of both intentional and non-intentional consequences – what we call secondary effects – that are then likely to become conditions for subsequent action.

Conclusion

This qualitative study helps shed light on the complex causal loops of interrelated factors that shape the work of GPs.