Evidencebased medicine knowledge, attitudes ... - Wiley Online Library

Journal of Evidence-Based Medicine ISSN 1756-5391

ORIGINAL ARTICLE

Evidence-based medicine knowledge, attitudes, and practices among doctors in Sri Lanka Chrishantha Abeysena, Pushpa Jayawardana, Rajitha Wickremasinghe and Uthpala Wickramasinghe Department of Public Health, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka

Keywords Attitudes; Evidence-based practice; Knowledge; Physicians; Survey Correspondence Chrishantha Abeysena, Department of Public Health, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka. Tel: 0094-11-2953411 Fax: 0094-11-2958337 Email: [email protected] , [email protected]

Received 28 August, 2009; accepted for publication 16 March 2010. doi: 10.1111/j.1756-5391.2010.01077.x

Objective To assess knowledge, attitudes, and practices on evidence-based medicine (EBM) among doctors in selected hospitals in Sri Lanka. Methods A cross-sectional descriptive study was conducted among 315 doctors in five government hospitals in Sri Lanka between December 2007 and January 2008. A pre-tested self-administered questionnaire was used to gather information on knowledge, attitudes, and practices. Results Of the 407 invited, 315 doctors participated, among whom, 87% (271) had heard the term EBM, 30% (n = 94) were aware of the Cochrane Library, and 8.5% (n = 27) were current users of it. Forty-seven per cent (n = 148) claimed to understand the terms systematic review and 37% (n = 115) meta-analysis. Twentyfour per cent (n = 77) had been exposed to some form of EBM training. All three components of EBM were known by 18% (n = 56) of participants. Attitudes toward EBM were positive among 76% (n = 239), 80% (n = 251) believed the practice of EBM would lead to improved patient care, and 77% (n = 243) considered EBM to be fundamental to professional practice. Just 3% (n = 13) considered it unimportant. EBM was used in clinical practice by 54% (n = 169) of participants. Thirty-six per cent (n = 114) referred to EBM sources when relevant. Available clinical guidelines were referred to by 56% (n = 176), and 34% (n = 107) thought that available guidelines provide sufficient support for the practice of EBM. The main barriers to practicing EBM were insufficient resources, overwork, lack of exposure to EBM, and lack of time and lack of endorsement of the need to practice EBM. Conclusions Knowledge and practices of EBM among Sri Lanka doctors were poor. However, attitudes toward EBM were relatively good.

Introduction Evidence-based medicine (EBM) is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (1). The process of inferring the ‘current best evidence’ involves a structured and systematic analysis of available literature. EBM is the integration of best research evidence with clinical expertise and patient values (1). In the provision of health care, enormous numbers of treatment decisions are made by clinicians. Evidence-based clinical practice is an approach to decision-making in which the clinicians use the best evidence available, in consultation with

the patient, to decide upon the option that suits the patient best. There are many advantages to practicing EBM. Those patients who receive evidence-based therapies have better outcomes than those who do not (2). Further, EBM practice includes improving clinical and communication skills and fostering generic skills in searching, appraising and implementing evidence from basic and applied sciences. For developing countries, it is particularly important to use healthcare resources efficiently through evidence-based decision-making. A growing number of relevant systematic reviews can assist policymakers, clinicians, and consumers in making informed decisions. Guidelines and reliable research

c 2010 Blackwell Publishing Asia Pty Ltd and Chinese Cochrane Center, West China Hospital of Sichuan University JEBM 3 (2010) 83–87

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summaries based on good evidence also help to establish professional standards (3). In order to further the practice of EBM in South Asia, the coordinating site of the South Asian Cochrane Network (SACN) was established in 2005 at the Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka. Since then, the site has been conducting a series of workshops and seminars on EBM. Currently EBM is included in some undergraduate as well as postgraduate (PG) medical curricula. Nevertheless, EBM remains a relatively new concept in Sri Lanka, and only a few universities have incorporated EBM into their undergraduate and PG curricula. Causing any paradigm shift in medical practice involves influencing the knowledge, attitudes and practices of individuals, and implementing EBM is no different. In order to identify areas for improvement in EBM implementation, we surveyed doctors in selected hospitals in Sri Lanka’s Western province about their knowledge of, attitudes toward, and practice of EBM.

Methods Population This cross-sectional hospital based descriptive study was carried out in five hospitals: National Hospital Sri Lanka; Colombo North Teaching Hospital; Chest Hospital, Welisara; Rheumatology Hospital, Ragama; and District General Hospital, Gampaha. The 315 eligible respondents included specialists, PG trainees and grade medical officers (GMO) [those without any PG qualifications]. Pre-intern medical officers were excluded.

Survey instrument, definitions, and data analysis A pre-tested self-administered questionnaire was used to gather information on knowledge, attitudes and practices. Questions included knowledge on the definition of EBM and technical terms used in EBM, attitudes toward EBM, and perceived barriers to practicing EBM. The questionnaire was constructed based on available literature on the topic to ensure content validity. Only general questions were selected, ensuring applicability to individual clinicians’ situations. All questionnaires were distributed personally by one of the authors and collected by the same to minimize the nonresponse rate. The Likert scale was used to assess the responses on perceived knowledge of technical terms related to EBM, attitudes toward EBM, and barriers for practicing EBM. SPSS 13.0 software was used for statistical analysis. Likert scaled responses were collapsed into two categories based on opposing responses. For other questions, proportions of correct answers were calculated. The data were analyzed separately

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for specialists and PG trainees together (because these two categories are constantly in the process of upgrading their knowledge), and GMOs. The Chi2 test was used to determine statistical significance between groups and a two-tailed P value less than 0.05 was considered significant.

Ethical approval The Ethics Review Committee of the Faculty of Medicine, University of Kelaniya, Sri Lanka, granted ethical approval.

Results The questionnaire was distributed to 407 doctors, of whom 315 responded, giving a nonresponse rate of 23% (n = 92). The participants included 43 (14%) specialists, 50 (16%) PG trainees, and 222 (70%) GMOs. The median length of work experience of participants was 6 (range 2–30) years and their mean age was 38 ± 5.4 years. One hundred and seventy (54%) were males. More than 80% of the participants had heard of the term EBM (Table 1), and 24% of participants were exposed to some training in EBM. Awareness of the Cochrane Library was 12% among GMOs. Less than 18% of participants were aware of all three components of EBM. Less than 73% of specialists and PG trainees and less than 38% of GMOs understood the phrase systematic review and meta-analysis. The understanding of number needed to treat (NNT) and risk difference was poor in both groups. More than 88% of specialists and PG trainees and 70% of GMOs had positive attitudes toward EBM (Table 2). More than 70% believed that EBM led to improved patient management. There was a significant difference in the percentages of specialists and PG trainees (84%) and GMOs (41%) currently using EBM in the management of patients (Table 3). Sixty-seven (52%) GMOs who did not practice EBM responded that they would do so if they were given the opportunity; among the 15 specialists and PG trainees not practicing EBM, the percentage was 94% (n = 14) (Table 3). Sixty-five per cent of respondents had access to EBM resources at their workplace, 146 (46%) had facilities where they could access journals, 120 (38%) had access to the Internet, and 144 (46%) had access to clinical guidelines. Half (n = 157) of participants had read articles related to EBM such as evidence-based summaries, and abstracts of systematic reviews and randomized controlled trials. Of those who had read EBM-related articles, 81 (51%) read at least one article per month, 41 (26%) read 2–3 articles, and 122 (77%) read more than 5 per month. Thirty-four per cent (n = 75) of respondents always referred to EBM sources when encountered with a clinical scenario that requires a referral to


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Table 1 Awareness and knowledge on EBM Specialists and PGa trainees (N = 93)

Grade Medical Officers (N = 222)

Both groups (N = 315)

Question/Statement

n

%

n

%

n

%

Heard the phrase ‘EBM’b Been exposed to any form of trainingb Know key components of EBMb All three components Only two components Only one component Did not know any Heard of ‘Cochrane Library’b Understand the following concepts Risk differenceb Number needed to treatb Systematic reviewsb Meta-analysisb

92 41

99 44

179 36

80.6 16.2

271 77

86 24.4

17 23 50 3 68

18.3 24.7 53.8 3.2 73

39 53 75 55 26

17.6 24 33.8 24.8 11.7

56 76 125 58 94

17.7 24 39.7 18.4 30

40 55 65 68

43 59 70 73

67 84 83 47

30.2 37.8 37.4 21

107 139 148 115

40 44 45 36.5

a b

PG: Postgraduate. The difference between the two groups were statistically significant.

EBM and 83 (26%) had never referred Less than 9% were current users of the Cochrane Library, and 83% had never used it. Available clinical guidelines were used by 56% (n = 176) of participants; 34% (n = 107) of participants stated that such guidelines were of value in supporting EBM practice. A higher percentage of GMOs than specialists and PG trainees followed relevant clinical guidelines in managing patients, but the difference was not statistically significant. The main barriers for practicing EBM among GMOs were insufficient resources, lack of exposure to EBM, and patient overload. Among specialists and PG trainees, insufficient resources was the largest barrier, followed by patient overload (Table 4).

Discussion Knowledge of EBM was poor, but attitudes toward EBM were relatively good among surveyed doctors. Awareness and use of the Cochrane Library was very low. Although

more than half of participants use clinical guidelines for patient management, two-thirds claimed that guidelines did not provide sufficient support for the practice of EBM. The main barriers to practicing EBM were insufficient resources, work overload, and lack of exposure to EBM. Previous studies on EBM awareness and practice have been limited. Our results are similar to those of a recent United Kingdom study (4). Our finding that knowledge of NNT and risk difference was less than 44% in all groups accords with results from Saudi Arabia (5), where knowledge on risk difference was less than 33%. However, that study did not assess the other concepts that we assessed. Undergraduate curricula encourage the use of textbooks for the acquisition of current medical knowledge, even though they are often outdated (6). EBM should be included in undergraduate training programs from entry to exit, covering identification, appraisal and application of evidence in the context of individual patient scenarios. Studies have reported that integration of EBM training into undergraduate medical

Table 2 Attitude toward EBM Specialists and PGa trainees (N = 93)



Attitude

n

%

n

%

n

%

‘Welcoming’b Led to ‘improved patient care’b Is a waste of time Is fundamental to professional practiceb

82 86 1 86

88.2 92.5 1 93.4

157 165 12 157

70.7 74.3 5.4 70.7

239 251 13 243

75.8 79.7 4 77

a b

PG: Postgraduate. The difference between the two groups was statistically significant.


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Table 3 Practice of EBM Specialists and PGa trainees (N = 93)



Practices

n

%

N

%

N

%

Currently use EBM in the management of patientsb Would use EBM given the opportunityb Have access to EBM resources at workplaceb Read research articles related to EBMb Cochrane Libraryb Current users Never used Always refer to sources of EBM when the need arisesb Always follow the relevant clinical guidelines in management of patients Current clinical guidelines sufficiently support the practice of EBMb

77 14 78 82

83.6 93.0 85.0 88.0

92 67 126 75

41.4 51.5 56.7 33.8

169 81 204 157

53.6 62.3 64.8 50.0

24 50 39 49 48

26.0 54.0 42.3 52.7 52.0

3 210 75 127 59

1.0 95.4 33.7 57.2 26.5

27 260 114 176 107

8.6 82.5 36.0 55.8 34.0

a b

PG: Postgraduate. Chi2 test: the difference between the two groups were statistically significant.

curricula improves EBM knowledge and skills, receptivity EBM use among medical students, and ability to meet the challenges of practicing EBM (7–9). Short courses in EBM have similarly been shown to improve EBM knowledge and skills among PG (10). More than three-quarters of participants in this study had a favorable attitude toward EBM, and a similar number claimed that EBM led to improved patient management. Our findings are consistent with a study conducted in Saudi Arabia (5) which reported that EBM improves patient care. In Singapore, more than half of respondents had positive attitudes toward EBM and three-quarters believed that EBM improves patient care; conversely, 7% did not think so (11). In Germany, 80% of ambulatory care physicians regarded EBM as the best basis for patient care (12). A qualitative study conducted among Australian general practitioners also reported positive attitudes toward EBM (13). Studies conducted in the United States have shown positive changes in the EBM attitudes, skills and practice of residents after EBM courses were integrated into the curriculum as part of clinicals (8,9). Australian surgeons believe that general knowledge on EBM is helpful and is commonly used in daily clinical decision-

making; however, they believe that not using EBM would not affect their daily clinical decision-making adversely (14). Another study in United States reported that conducting courses improved the attitudes of medical students toward EBM (15). In the current study, even though 84% of both specialists and PG trainees used EBM currently in the management of patients, only 41% of GMOs did so. In 1997, 11% of Canadian physicians used EBM always, 59% often, 27% sometimes, and 3% never (16). In the UK (4) more hospital doctors than general practitioners practice EBM. In Singapore, 45% of physicians practice EBM in their daily patient management (11). In our study, half of the participants had read articles on EBM and 36% referred to EBM sources when relevant. Very few used the Cochrane Library. Similarly, only 14% of Saudi Arabian doctors were aware of the Cochrane Library (5). Studies have reported that training sessions on EBM have a marked beneficial effect on the quality of subsequent EBM literature searching performance (15,17). Half of our sample referred to clinical guidelines, the percentage being higher among GMOs than among consultants

Table 4 Perceived barriers to practicing EBM Specialists and PGa trainees (N = 93)



Barriers

n

%

n

%

n

%

Patient overloadb Insufficient resources Lack of personal timeb Lack of exposure to EBMb Lack of endorsementby health authoritiesb

64 78 57 51 51

71.0 87.6 62.6 58.6 60.0

146 167 147 154 135

83.4 92.2 83.0 86.0 81.3

210 245 204 205 186

66.6 77.7 64.8 65.0 59.0

a b

PG: Postgraduate. Chi2 test: significant difference between two groups.

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and PG trainees. In Canada, just one-quarter of physicians used clinical practice guidelines, and only 5% referred to Cochrane Reviews (16). Half of German physicians use clinical guidelines in the treatment of patients, but another onethird strongly rejected the application of guidelines to patient care (10). Two-thirds of our respondents believed that current clinical guidelines lack sufficient support for the practice of EBM. An Australian study reported that surgeons believed journal summaries of the latest research were more useful for clinical practice than were clinical practice guidelines (14). This points to the need for constant revisions of guidelines in keeping with the latest available evidence. The main barriers to practicing EBM among our sample were insufficient resources, patient overload, and lack of exposure to EBM and endorsement of the need to practice EBM by the health authorities. All the barriers were experienced by more GMOs than consultants or PG trainees. Other studies had reported that lack of time (4,5,11,18); inaccessible library, computer and Internet facilities (4,5,11,18); a nonconducive institutional culture (18); lack of endorsement by the seniors (11); lack of relevant evidence (16); newness of the EBM concept and its perceived impracticality in day to day practice (16); and lack of exposure to EBM in undergraduate curriculum (11) are major barriers to practicing EBM. Our study is not devoid of limitations. For example, we found that less than two-thirds of our sample had access to EBM resources at the workplace. As our study was based in teaching hospitals, we expect that availability is even lower nationally. It is also likely that perceived knowledge of EBM was over-reported. Based on these considerations, it is likely that the knowledge and application of EBM at national level is much less than the results presented here. In conclusion attitudes toward EBM was relatively good among Sri Lankan doctors even though knowledge and practices of EBM were poor. Recommend strengthening of EBM training among undergraduates, provision of in-service training and facilities to engage in EBM for practicing doctors and a change in the culture. References 1. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practice and Teach EBM. New York: Churchill and Livingstone, 1997. 2. Shortell MS, Rundall TG, Hsu J. Improving patient care by linking evidence-based medicine and evidence-based management. JAMA 2007; 298: 673–6. 3. Garner P, Kale R, Dickson R, Dans T, Salinas R. Getting research findings into practice Implementing research findings in developing countries. BMJ 1998; 317(7157): 531–5. 4. Upton D, Upton P. Knowledge and use of evidence-based practice of GPs and hospital doctors. Journal of Evaluation in Clinical Practice 2005; 12(3): 376–84.


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