The assessment of doctors' knowledge, practice and barriers of evidence-based medicine (EBM) in Hospital Seberang Jaya.
KPB EBM HSJ
General Information
Study Information
Evidence-based medicine is defined as the integration of best research evidence with clinical expertise and patient values. 1
EBM can help doctors to be up to date with the latest management of the disease, help to answer the patients concern or question and help with the decision-making together with the patient. EBM is a very important skill and every healthcare professional (HCP) especially doctors should apply EBM in their daily clinical practice. However, not everyone knows how to apply EBM and this could be due to lack of knowledge or they are unable to practise due to some barriers in implementing EBM.
A literature search was done on the doctors' knowledge, practice and barriers in implementing EBM in clinical practice all over the world and there are many papers found related to the search, but only those related to doctors were chosen to be discussed for the purpose of this study.
1.1.1Knowledge, Practice, Attitude And Behaviour Towards EBM Among Doctors
In a systematic review done by Barzkar et al. (2018) with the literature search up to September 2017, concluded that many physicians have poor EBM knowledge and skills, however, most of them have a positive attitude toward the implication of EBM.2
In France, Lafuente et al. (2019) reported that 64% of physicians never practise EBM and among them 32% never know what is EBM or just heard of it. Only 19% of them practise EBM regularly. There were no associated factors found in the level of knowledge and the use of EBM among physicians.3
Worku et al. (2019) studied Ethiopian physicians knowledge of EBM by using a questionnaire adapted from The McColl and the BARRIERS scale questionnaires. It was found that physicians knowledge of EBM resources ranged from 29.8% (Cochrane) to 75% (Google). About 19.4% to 44.4% could understand and explain the EBM technical terms. Even though 88.7% of physicians have a good attitude to EBM but only 32.3% practise it.4
Hong et al. (2019) reported that 58% physicians in China knew moderately about EBM. Even their level of perceptions of the importance of clinical evidence, patients value and personal experience in decision-making process is up to 96.9% but their competency and skill in EBM is still low.5
Capras et al. (2020) found that most of the Romanian physicians able to define EBM correctly (75.6%). Generally they have positive attitudes towards EBM but limited knowledge on EBM.6
As an overall, it shows that the level of doctors knowledge and practise towards EBM is varies among countries and generally it is still in a low to moderate level. Furthermore, there is no published data on Malaysian doctors knowledge and practice of EBM available as for our search.
1.1.2Barriers In Implementing EBM Among Doctors
Systematic review of Barzkar et al. (2018) stated that the common barriers of practicing EBM among clinician were lack of time, patient overload and limited financial resources and facilities.2
Among the barriers identified by Worku et al. (2019) are organization doesnt have access to non-free electronic databases (62.1%), they dont know how to find research reports (53.2%), insufficient time and lack of interest to find research reports (51.7%), insufficient resources to change own practice (76.6%), insufficient time at work to implement changes in own practice (58.1%) and team culture was not receptive to changing practice (58.1%). And it was found that, understanding of research reports, ability to retrieve evidence and evaluate the outcome were associated with the implementation of EBM in their practice.4
Hong et al. (2019) identified that physicians attitudes and their evidence-based practise skills have effected by a personal interest and organizational factors such as workload and hospital requirement.5
Some of the barriers that were found in these papers such as doctors knowledge and skill on how to find the best evidence and how to interpret the research findings could be overcome by teaching the physicians on how to do the proper literature search and the interpretation of the findings and terms related to research by a training such as EBM workshop. Since time is a major concern among doctors, the workshop can be done in 1 day and covering the major topics in EBM such as literature search, critical appraisal and interpretation of research findings. Improvement in EBM knowledge might improve the practice in EBM as well if they find it easy and understandable.
1.2The Impact Of Ebm Related Training On The Doctors' Knowledge, Attitude And Practice Of EBM
Few studies have looked into the impact of EBM related training on the knowledge and practice of EBM among doctors.
In a pre post study done in 2007 among primary care doctors in urban clinics showed that their knowledge of EBM significantly improve after the EBM workshop. The improvement of doctors knowledge score is significantly associated with their specialization (2.7 times more among specialist) and their habit of reading medical journals (1.5 times more among readers). However, no significant change in the EBM practise noted after the workshop even they have a positive attitude towards EBM.7
In a systematic review done up to September 2014 by Hecht et al. (2016), also found that EBM training has some improvement in the knowledge but not a significant behaviour changes noted towards EBM.8
Another systematic review done by Simon 2019 whereby the literature search were done up to 2016 showed that EBM courses have a short-term improvement in knowledge but not in the clinical practise changes.9
In a randomised controlled trial conducted by Al-Baghli et al. (2013), after the EBM workshops, the physicians knowledge improved from 38.9% on pre-test to 81.4% post-test, and the score sustained up to 66.8% at 4 months post-intervention test.10
Similar finding, reported by Allen et al. (2018), where a pre post study among physician and surgeon in Canada who attended a 1-day EBM workshop was conducted and was found that the comfort level of practising and teaching EBM was improved and sustained at 3-6 months.11
Nasr et al. (2018) stated that a 2-day EBM workshop among physicians was able to improve the knowledge of critical appraisal.12
In a study comparing standard stand-alone 2-day EBM workshop versus those exposed to deliberate EBM practice, Draaisma et al. (2020) reported that those with deliberate EBM practise more likely uses EBM principles in medical decision making, and practise EBM in their daily clinical practice.13
Generally it shows that EBM related training or workshop might improve the doctors knowledge, but changes in practise is still not easily achievable even with a positive attitude towards EBM among doctors. Therefore, barriers in implementing EBM among doctors also need to be studied.
1.2.1EBM Workshop in HSJ
Evidence-based Medicine Workshop is one of the important workshop which will be organised by Clinical Research Centre (CRC) HSJ yearly. A several workshops will be conducted in a year, depending on the demands of healthcare professionals from various departments in HSJ and mostly from those working in clinical settings. The objectives of the EBM workshop are to introduce the doctors and other healthcare professionals to the principle of EBM and teach them on how to find and use the best evidence to answer their clinical question.
The workshop is a face-face workshop which is conducted in a small group of healthcare professionals (10-20 participants) from various departments. It is a 1-day workshop which will be covering four main topics of EBM:
a)PICO & Literature Search - teaching on how to formulate an answerable question and how to find for the best evidence
b)Critical Appraisal of Randomised Controlled Trial (RCT) - teaching on how to critically appraise the RCT papers using RAMBoo method
c)How to interpret the results? - teaching on how to calculate and interpret the following terms; Absolute risk reduction (ARR), Relative risk reduction (RRR), Relative risk (RR), Odds ratio (OR), Number needed to treat (NNT), Sensitivity (Se) & Specificity (Sp) and Positive predictive value (PPV) & Negative predictive value (NPV).
d)Critical Appraisal of Systematic Review - teaching on how to critically appraise the systematic review papers and introduce to the following terms; meta-analysis, Forest plot, heterogeneity test, publication bias and Funnel plot for the interpretation of the findings.
The content of the slides for the topics are adapted from various EBM tutors or EBM experts and some of the contents also adapted from EBM Workbook:Bridging the gap between heath care research and practice 2nd edition.
The presenters and the facilitators are the CRC HSJ staffs who have attended EBM workshop previously and have experience in teaching EBM. Each topic will take about 1 hour - 1.5 hours including the groups discussion part. During the Covid pandemic, the EBM workshop slightly modified whereby the small group discussion will be omitted and replaced with single group discussion where all the participants will join the same discussion immediately after the talk. The participant sitting arrangement and other procedures will be followed according to the current SOP implemented during the Covid pandemic.
At the end of the workshop, all the participants are required to fill in the workshop evaluation form which will be shared via Google form. Certificate of attendance will be given to all the participants who successfully complete the workshop.
So far, we have never assessed the knowledge and practice of EBM among doctors in HSJ after they have attended the EBM workshop and there is no data on the sustainability of the knowledge post EBM workshop among participants in HSJ available.
1.3Tool for assessment of EBM
There are many tools available for the EBM assessment on the knowledge, attitude, practise, behaviour and barriers. Among that, the validated tools are;
Berlin Questionnaire14
assess knowledge and skills in EBM
15-item multiple choice
Fresno test15
assess medical professionals EBM skills and knowledge.
12 open-ended questions based on clinical scenario.
Assessing Competency in Evidence‐Based Practice (ACE tool)16
assess medical trainees competency in EBM
15-items multiple choice based on clinical scenario
The only available tool validated in Malaysia is Evidence‐Based Practice Questionnaire (EBMQ) which is validated among primary care physicians in Malaysia to assess knowledge, practise and barriers regarding the implementation of EBM.17
Flesch reading ease was 61.2.
Consist of eight domains: EBM websites, evidence-based journals, types of studies, terms related to EBM, practice, access, patient preferences and support with 42 items.
Cronbach alpha for the overall EBMQ was 0.909 and for the individual domain ranged from 0.6570.940.
The EBMQ able to discriminate between doctors with and without EBM training.
Kappa values via test-retest ranged from 0.155 to 0.620.
The higher score indicates better knowledge and better practice of EBM and less barriers in practising EBM.
1.4Aim of the study:
The study's main purpose is to assess the knowledge, practice and barriers regarding implementing EBM in clinical practice among doctors in HSJ and to assess the impact of EBM workshop on their knowledge and practice of EBM.
Knowledge
Practice
Barriers
EBM workshop
To assess the knowledge, practice and barriers regarding implementing EBM among doctors in HSJ.
Specific Objectives
Phase 1:
1.To assess the knowledge, practice and barriers regarding implementing EBM in among doctors in HSJ.
2.To determine the association between knowledge, practice and barriers score with the sociodemographic factors;
a)Age, gender, designation, department, years of service, postgraduate qualification,
b)Have heard of evidence-based medicine,
c)Have attended EBM courses,
d)Have conducted research after graduating from medical school,
e)Have published any article in a journal
Phase 2:
3.To assess the mean score difference in knowledge, practice and barriers regarding implementing EBM among doctors who participating in EBM workshop before (T0) and after the workshop at different time point [immediately post workshop (T1) & at 3-6 months post workshop (T2)].
4.To determine the association between knowledge, practice and barriers score differences with the sociodemographic factors;
a)Age, gender, designation, department, years of service, postgraduate qualification,
b)Have heard of evidence-based medicine,
c)Have attended EBM courses,
d)Have conducted research after graduating from medical school,
e)Have published any article in a journal
Inclusion & Exclusion Criteria
Study Timeline
Gender :
Sites
Team Members
HOSPITAL SEBERANG JAYA
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