The place of evidence-based medicine among primary health care

The place of evidence-based medicine among primary health care

Family Practice © Oxford University Press 2002 Vol. 19, No. 5 Printed in Great Britain The place of evidence-based medicine among primary health car...

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Family Practice © Oxford University Press 2002

Vol. 19, No. 5 Printed in Great Britain

The place of evidence-based medicine among primary health care physicians in Riyadh region, Saudi Arabia Lubna A Al-Ansary and Tawfik A Khojaa Al-Ansary LA and Khoja TA. The place of evidence-based medicine among primary health care physicians in Riyadh region, Saudi Arabia. Family Practice 2002; 19: 537–542. Background. Evidence-based medicine (EBM) is a style of practice in which doctors manage problems by reference to valid and relevant information. Unfortunately, research consistently has shown that clinical decisions rarely are based on the best available evidence. Since primary care is the essential foundation in effective health care systems, it follows that providing evidence-based primary care would reflect positively on the community’s health. Objectives. Our aim was to explore the awareness and the attitude of primary health care physicians (PHCPs) towards evidence-based medicine (EBM) and determine their related educational needs. Methods. A questionnaire study was carried out of all 650 PHCPs practising at the Ministry of Health Primary Health Care Centres in Riyadh region, Saudi Arabia. Main outcome measures were respondents’ attitude towards EBM, ability to access and interpret evidence, perceived barriers to practising EBM and the best method of moving from opinion-based medicine to EBM. Results. Respondents (n = 559) mainly welcomed EBM and agreed that its practice improves patient care. They had a low level of awareness of extracting journals, review publications and databases, and even if aware, many did not use them. The most commonly read journals by the PHCPs were The Practitioner and Medicine Digest. Only 16% had access to bibliographic databases and 10% to the worldwide web. The respondents showed a partial understanding of the technical terms used in EBM. The major perceived barriers to practising EBM were patient overload and lack of personal time. Respondents thought that the most appropriate way to move towards EBM was by learning the skills of EBM (43%), followed by using evidence-based guidelines developed by colleagues (37%). Conclusions. Efforts towards improving access to evidence-based guidelines and summaries are urgently needed. Teaching all the PHCPs literature searching and critical appraisal skills by feasible and friendly methods should be considered. Keywords. Attitude, awareness, evidence-based medicine, primary health care, Saudi Arabia.

proportion of interventions in primary care that are based on evidence.7 Several surveys, however, have reached the conclusion that clinical decisions are rarely based on the best available evidence.8–11 It is strongly believed that if the concept of delivering an evidence-based practice (EBP) is embraced, it will improve primary care in a number of different ways. First, it will support shared decision making with users, which is advocated increasingly as the ideal model for making decisions within the medical encounter.12,13 Secondly, EBP will help maintain the central role of family medicine in health care.14 Finally, it will make general practice an even more rewarding discipline within which to practise.2 No information is available in Saudi Arabia on the interest of primary care physicians in the use of

Introduction Recent papers have highlighted the need for evidencebased (EB) family medicine,1,2 the role of EB guidelines3–5 and EB performance indicators6 in the management of conditions common to general practice and the estimated Received 26 July 2001; Revised 11 December 2001; Accepted 13 May 2002. Department of Family and Community Medicine, College of Medicine, King Saud University and aExecutive Board of the Health Ministers Council, GCC states, Saudi Arabia. Correspondence to Dr Lubna A Al-Ansary, MSc, FRCGP, Associate Professor, Department of Family and Community Medicine, College of Medicine, King Saud University, PO Box 2925, Riyadh 11461, Saudi Arabia; E-mail: [email protected] or [email protected]

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evidence-based medicine (EBM). The objectives of this study are to explore the awareness and the attitude of primary care physicians towards EBM and, hence, their related educational needs to incorporate such practice into their routine patient management. The study is based on the recent work of McColl et al., which was carried out to determine the attitude of UK GPs towards EBM.15

Methods The study design is a cross-sectional questionnaire survey. The study population consists of all primary health care physicians (PHCPs) practising in the Primary Health Care Centres (PHCCs) in Riyadh Region. Riyadh region is the central and one of the largest regions in Saudi Arabia. It is served by a total of 275 PHCCs distributed as follows: 59 in Riyadh city, 112 in smaller cities and 104 rural PHCCs.16 The questionnaire was adapted from McColl et al.15 Using a previously published questionnaire was thought to add strength to the study because it has already been tested and because it would allow for an international comparison to be drawn. A pilot study was carried out in July/August 1999 which led to some modification and local adaptations. The covering letter for the questionnaire included Sackett’s definition of EBM: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Its practice means integrating individual clinical expertise with best available external evidence from systematic research”.17 Data included in the questionnaire were based on the following items: (i) Personal and PHCC characteristics. (ii) The PHCPs’ awareness of the availability of extracting journals, review publications and databases relevant to EBM and their usefulness; and their access to relevant databases and the worldwide web (WWW). (iii) Attitudes towards EBM. This part was assessed using visual analogue scales to determine the attitudes towards certain statements about EBM. (iv) Understanding of technical terms used in EBM (e.g. relative risk, systematic review, metaanalysis, odds ratio). The terms were listed and the PHCPs were asked to indicate their reactions to them. An actual test was also included to assess their baseline knowledge in an objective way. (v) Views on major barriers to practising EBM. (vi) Views on how best to move from opinion-based medicine to EBM. A space for free text was included to allow the PHCPs to express freely their views for items (v) and (vi). These

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statements were coded and grouped by one of the authors (LAA). In October 1999, the questionnaires were sent to all PHCPs who work in the PHCCs in Riyadh region (650 physicians) via the MOH General Director of PHCCs and Regional Assistant Director as this was thought to be the easiest way to communicate with the PHCPs. Reminders were sent to non-respondents in December 1999. Analysis was carried out addressing the following main outcome measures: respondents’ attitudes towards EBM, ability to access and interpret evidence, perceived barriers to practising EBM and the best method of moving from opinion-based medicine to EBM. The Epi info statistical computer program (Epi 0.6) was used for the statistical analysis. The three PHC settings (urban, suburban and rural) were compared using analysis of variance or the chi-square test. P-levels 0.05 were considered statistically significant.

Results Of the 650 questionnaires sent out, 559 replies (86%) were received. The largest proportion of the PHCPs were practising in urban areas (47%), compared with 28% in the mixed and 25% in the rural districts. The mean age of the responding PHCPs was 41.7 years, with 66.9% male and only 3.8% Saudis. On average, they had graduated 19.6 years previously and had been practising for 6.6 years in primary health care. The PHCPs are mostly working in practices with 2–5 partners, most seeing ~59 patients a day. The practices were evenly distributed between urban, suburban and rural settings. The mean time to reach the nearest medical library was 36.3, 63.9 and 82.4 min for the urban, mixed and rural centres, respectively. Attitudes towards EBM Figure 1 shows the attitudes of the responding PHCPs towards EBM. The current promotion of EBM was welcomed by most of them. They thought that their colleagues’ attitudes were welcoming as well. Most of them agreed that practising EBM improves patient care, and expressed the opinion that research findings were useful in their daily management of patients. The majority disagreed with the notion that EBM was of limited value in primary care but agreed that the adoption of EBM places another demand on already overloaded PHCPs. The median value for the estimated percentage of the respondents’ clinical practice that was EB was 68%. Awareness and perceived usefulness of relevant information sources Approximately 37% of the PHCPs were aware of the American College of Physicians Journal Club and Evidence-Based Medicine. A quarter were aware of

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FIGURE 1

The attitudes of PHCPs in Riyadh region towards EBM

the Effective Health Care Bulletins. Only 16.6 and 14.4% were aware of Best Evidence and The Cochrane Database of Systematic Reviews, respectively. Less than 4% used any of these resources in clinical decision making. Reading of local and Middle Eastern editions of journals The Practitioner and Medicine Digest were the most regularly read journals (29.9 and 24.0%, respectively), followed by Modern Medicine (23.1%) and The PG Doctor (22.1%). Locally published refereed journals, which are available by subscription only, were not the favourite ones (regularly read by 3.7–12.7%). Access to the relevant databases and the worldwide web Only 16% of the PHCPs had access to Medline or other bibliographic databases, and only 10.2% had some kind of access to the WWW. In the previous year, 4.8% had used Medline or another database for literature searching. Of the respondents, 11.7% reported having training in literature searching, 4.1% attended a course on practising EBM and only 2.3% attended courses on critical appraisal. On the positive side, almost all of them (95.3%) would like to attend courses relevant to practising EBM. Understanding of technical terms used in EBM The respondents were comfortable with most of the technical terms (risk factor, sensitivity, specificity, relative and absolute risks), and a sizeable proportion felt that they could explain them to others. Odds ratio, likelihood ratio, meta-analysis and publication bias were the terms that were poorly understood.

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Baseline knowledge of PHCPs More than 85% of PHCPs attempted to answer questions on the measures of central tendency, and the majority did well (Table 1). Questions on the validity and predictive values were attempted by 60% of the respondents only. Of these, 60% answered the questions correctly. Views on major barriers to practising EBM The major perceived barriers to practising EBM in primary care was patient overload (29.4%), lack of free personal time (21.5%), no library in the locality (16.3%), limited resources and facilities (14.4%), and lack of TABLE 1

Assessment of the baseline knowledge of PHCPs in Riyadh region

Sensitivity

Correct

Incorrect

Blank

218 (39.0)

117 (20.9)

224 (40.1)

Specificity

184 (32.9)

151 (27.0)

224 (40.1)

Positive predictive value

205 (36.7)

129 (23.1)

225 (40.3)

Negative predictive value

220 (39.4)

114 (20.4)

225 (40.3)

Odds ratio

281 (50.3)

52 (9.3)

226 (40.4)

Absolute risk

182 (32.6)

263 (47.0)

114 (20.4)

Mean

335 (63.5)

129 (23.1)

75 (13.4)

Mode

354 (63.3)

128 (22.9)

77 (13.8)

Median

378 (67.6)

104 (18.6)

77 (13.0)

Standard deviation

335 (63.5)

126 (22.5)

78 (14.0)

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scientific media and continuing medical education (CME) (11.4%). The attitudes of the patients were perceived as a barrier by 9.0% of the respondents only. Views on how best to move from opinion-based to EBM More than half of the respondents claimed to be practising EBM currently by seeking and applying EB summaries, yet only 20.4% thought that this would be the most appropriate way to practise EBM. The largest proportion of the PHCPs (42.6%) thought that the best way to move from opinion-based medicine to EBM was by learning the skills of EBM (two-thirds claimed to be doing so currently) while 37% thought it should be by using EBP guidelines or protocols developed by colleagues for use by others. One-tenth of the respondents were undecided (Table 2).

Discussion In an environment with an increasing focus on both the accountability of health expenditure and identification and measurement of health outcomes for all health interventions, it would be hazardous to ignore EBP by primary care physicians.10,11,13,18,19 The welcoming attitudes of the PHCPs are similar to those of British15 and Australian20 GPs. The median value for the estimated percentage of the respondents’ clinical practice that was EB was 68%. This is higher than the figure of 50% reported by McColl et al.15 It is a subjective estimate, however, which has its limitations. The past few years have witnessed a worldwide plethora of books, workshops and courses on how to practise and teach EBM. The Cochrane Library has an increasing number of systematic reviews relevant to primary care. Evidence-Based Medicine and the American College of Physicians Journal Club as well as other online summaries of scientifically sound and clinically relevant articles are becoming increasingly available for family physicians.21–23 The PHCPs in Riyadh, however, had a low level of awareness of well-known resources of EBM and, even if they were aware, did not make use of them in clinical decision making. The classical definition of EBM put

TABLE 2

forward by Sackett et al. involves integrating individual clinical expertise with the best available external research evidence.17 Without using current best evidence, the practice of PHCPs possibly is at risk of becoming out of date, to the detriment of patients.24,25 This is very probably because it has been shown that a significant negative correlation exists between our knowledge of up-to-date care and the years that have elapsed since graduation from medical schools.26 The finding that the most regularly read journals were those distributed free, which are sponsored by drug companies, may be valuable in planning for the inculcation of evidence among PHCPs. These journals can be used for disseminating the concept and steps of practising EBM, as well as EB summaries and guidelines. Only 16 and 10.2% of the PHCPs had access to Medline and to the WWW, respectively. The past couple of years, however, have witnessed a widespread governmental and private uptake and utilization of the Internet; consequently, the corresponding figures may now be higher. Although it has been shown recently that the printed Index Medicus is still the most effective literature retrieval method for GPs,27 there is a need to train PHCPs in electronic literature retrieval methods. The Internet fosters the practice of EBM by facilitating the generation, synthesis, dissemination and exchange of research evidence.28 It enhances the role of EB decision making by giving the PHCPs cheap, fast and efficient access to up-to-date, valid and relevant knowledge at the right time and place, and in the right amount and format. The respondents in McColl’s study apparently were more familiar with the technical terms commonly used in EBM, but one should keep in mind that only 13 doctors (2.3%) in the Riyadh region have attended courses on critical appraisal, in contrast to 39% in the UK.15 Interpretation of evidence, however, is a key element in practising EBM, and this partial understanding could hinder interpretation and make dissemination of evidence to other members of the primary care team or patients more difficult.15 The major perceived barriers to practising EBM in primary care were patient overload (29.4%) and lack of free personal time (21.5%). Patient overload possibly would also translate into lack of time, making the total

Views of the responding PHCPs on ways of moving from opinion-based practice to evidence-based practice

Method of moving towards EBM

Method currently useda

Method of interest for future usea

Most appropriate method

Learning the skills of EBM

355 (67.1)

316 (58.3)

213 (42.6)

Seeking and applying evidence base summaries

295 (55.8)

282 (52.0)

102 (20.4)

Using evidence-based practice guidelines or protocols

251 (47.4)

254 (46.9)

185 (37.0)

Values are numbers (percentages). a Respondents were allowed more than one response.

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EBM in Saudi Arabia

50.9%. In McColl’s study, lack of personal time was also the main perceived barrier to practising EBM (71%). General physicians must come to grips with 19 original articles per day, 365 days per year, if they want to keep abreast of their field.29 Sackett30 and Dawes2 have suggested methods to spend time more efficiently. In McColl’s study, the attitudes of the patients were perceived as a barrier in 18% of the responses. The corresponding figure in our study was 9%. Research has shown that patients’ attitudes should not be ignored, as they may present a major impediment to most primary prevention programmes.31 As for the other perceived barriers to practising EBM, many have been discussed by Straus and McAlister,32 together with potential solutions. The largest proportion of the PHCPs (42.6%) thought that the best way to move from opinion-based medicine to EBM was by learning the skills of EBM, while 37% thought it should be by using EBP guidelines or protocols. In contrast, most of the respondents in McColl’s study (57%) thought that the most appropriate way was by using EB guidelines or protocols, while 37% thought it should be by seeking and applying EB summaries, and only 5% by identifying and appraising the primary literature or systematic reviews.15 This is an interesting contrast. It has been suggested that practising the traditional five steps of EBM is needed for the conditions that we encounter every day in order to be ‘up to the minute’ and very sure about what we are doing.24 This probably explains why a large proportion of respondents were interested in learning the skills of EBM. It has been found, however, that operating in the ‘appraising’ mode is time consuming and not suitable for busy overloaded practitioners,33 and the emphasis now is shifting towards ‘information mastery’ rather than traditional EBM.33,34 On a much deeper level, to put evidence into action, the evidence needs to be relevant to the recipient in the sense that it should answer questions that PHCPs really want answers to and not simply cover topics that are interesting or researchable.35 Furthermore, selecting the most appropriate strategy should relate to how the PHCP is most likely to react to new information about the effectiveness of clinical strategies that may affect many of their patients.36 With more prospective trials being carried out, changing clinical behaviours would become better understood and more effective.

needed to improve access and implementation of EB guidelines and summaries. On the other hand, teaching all the PHCPs the skills of practising EBM by feasible and friendly methods should also be encouraged. Strategies for encouraging change among the PHCPs and overcoming the barriers should be part of the decision makers’ vision. It is probably time to establish an EBM Saudi Board or Centre that will help to implant the principles, methods and practices among the PHC team members throughout Saudi Arabia. Lastly, patient values and expectations as well as ethical issues should play a role in determining whether and which interventions should be implemented.

Acknowledgements The authors thank all the PHCPs and the MOH directors who took part in this survey and made this work possible. We would also like to thank the scientific office of the MSD pharmaceutical company that has generously supported this study. We also extend our thanks to Professor Walter W Rosser, Chair, Family and Community Medicine at University of Toronto, Professor Abdolmonem A Afifi, Dean Emeritus and Professor of Biostatistics, UCLA School of Public Health, and Dr Mohammad A Balla, a senior lecturer in the Department of Family and Community Medicine at King Saud University, for reviewing the manuscript.

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Conclusions This study is the first of its kind in Saudi Arabia. The results are expected to help postgraduate tutors, MOHs and health authorities, university departments of Family and Community Medicine and local research centres in designing local strategies for encouraging the implementation of EBM in primary care. Prompt actions are

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