Editorial

Databases and evidence-based medicine in general practice

We have built it, but will they come?

MJA 1999; 170: 52-53

In the early 1990s, evidence-based medicine (EBM) became the focus for improving healthcare.1 Since then, there has been a steady stream of rigorously researched clinical practice guidelines,2 the birth of specialised extracting journals such as Evidence Based Medicine, Evidence Based Mental Health and Evidence Based Nursing and the inception and growth of the Cochrane Collaboration and the Cochrane Library. The latter includes the Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness, available either online or on CD-ROM.3

The essence of EBM is that decision making in healthcare should be influenced by the best available evidence and clinical experience, and the practice of EBM means integrating individual clinical expertise with the best external evidence from systematic research.⁴ Integral to this is access to, and interpretation of, the evidence in systematic reviews, meta-analyses, evidence-based practice guidelines and evidence databases.

The usefulness of evidence databases in real-time clinical practice was recently highlighted in the Journal by the report that 72% of Australian neonatologists and 44% of obstetricians regularly used evidence databases to guide their care of patients.⁵ In this issue of the Journal, Young and Ward report on Australian general practitioners' use of the Cochrane Library.⁶ Although 43% of GPs (14% at work) had access to the Internet and 22% were aware of the Cochrane Library, only 6% had access to it and 4% had ever used it. These findings are mirrored in the United Kingdom, where the Cochrane Library Database of Reviews has a higher recognition rate among GPs (40%) but the rate of use (4%) is remarkably similar.⁷ What the findings of Young and Ward mean for the current use of EBM in general practice awaits a comprehensive national study on the usefulness, relevance and framework of the tools of EBM in Australian general practice. Simplistic explanations for their findings include the low connectivity of our GPs to databases or the limited relevance of these databases -- which emphasise therapeutic interventions rather than diagnosis and prognosis or other types of clinical questions⁸ -- to general practice. General practice, which centres on the individual patient-doctor relationship and the interaction between biomedical, personal and contextual perspectives, may require different research strategies and allowance for more "circumstantial" evidence rather than the "watertight" evidence accrued by randomised controlled trials.⁹

It is ironic that with the emphasis on evidence in EBM there is so little published information on the attitudes of Australian GPs towards EBM, the education and skills they require to access and interpret evidence, and the support they need to incorporate EBM into everyday general practice. A recent UK survey of GPs has shed some light on these issues by showing that, although most GPs welcomed the move to EBM and agreed that this would improve patient care, there was a low level of awareness of extracting journals, review publications and relevant databases such as the Cochrane Library.⁷ While UK GPs expressed a desire to increase their knowledge of the methods and vocabulary of EBM, the major barrier they perceived to practising EBM was a lack of time.⁷ This finding strongly suggests that for EBM to succeed in general practice information needs to be relevant and available in the clinic within minutes rather than hours.⁸ Such information might be provided by an intermediate service,¹⁰ in the way that pathology or radiology services are currently provided to support GPs.

What are Australian GPs' perceptions of EBM? Although there is no information directly comparable with the UK findings, two local surveys^11,12 have found that:

• Topics identified by health policymakers for the development of guidelines are not necessarily synchronous with GPs' perceived needs;¹²

• The source of guidelines is critically important for the perceived credibility of guidelines (eg, in 1995 the Australian Cancer Society and the Australian Medical Association outranked nine other organisations, including the National Health and Medical Research Council [NHMRC] and the Royal Australian College of General Practitioners);¹² and

• Online dissemination of evidence is perhaps before its time, as GPs express a strong preference for guidelines in a booklet compiled in one official document -- a preference perhaps consistent with the respondents' low rate of Internet access at the time of the survey.¹²

Nonetheless, there is a need for comprehensive information on the context and use of EBM in Australian clinical practice. This requirement has recently been addressed by the NHMRC through its Evidence Based Clinical Practice Program, which promotes and funds research into strategies for implementing and sustaining the use of EBM in different Australian healthcare environments, and into the effect of EBM on patient outcomes.¹³ Answers for these critical questions are not expected before the year 2000.

Interventions to promote behavioural change among healthcare professionals Consistently effective interventions Educational outreach visits Reminders Multifaceted intervention combining two or more of: audit and feedback, reminders, local consensus processes, or marketing Interactive educational meetings in which healthcare providers participate in workshops Interventions of variable effectiveness Audit and feedback (or any summary of clinical performance) Promotion by local practitioners identified by their colleagues as influential Including participating practitioners in discussions to ensure that they agree that the chosen clinical problem is important and the approach to managing the problem is appropriate Any intervention aimed at changing the performance of healthcare providers for which specific information was sought from or given to patients Interventions that have little or no effect Distribution of recommendations for clinical care, including clinical practice guidelines, audiovisual materials, and electronic publications Didactic educational meetings such as lectures

All of these considerations revolve, of course, around the perception and usefulness of EBM in general practice. Another prerequisite for the widespread use of the paraphernalia of EBM in general practice is a change in GPs' behaviour. Interventions for influencing behaviour which may have some bearing on introducing research into clinical practice have been identified by Bero et al,¹⁴ and are summarised in the Box (above). The effectiveness of such interventions among Australian GPs remains to be explored. In the movie Field of Dreams (1989, Universal Studios), a farmer (Kevin Costner) builds a baseball stadium in the isolation of the midwestern cornfields of the United States to summon the ghosts of past players. With poignant conviction, he says, "Let's build it, and they will come". Although the framework of EBM has been built, will our profession come? What are appropriate tools and interventions for encouraging doctors, and particularly GPs, to practise EBM? On these questions, we need some real evidence.

Martin B Van Der Weyden
Editor, The Medical Journal of Australia

1. Evidence Based Medicine Working Group. Evidence based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268: 2420-2425.
2. Smallwood RA, Lapsley HM. Clinical practice guidelines: to what end? Med J Aust 1997; 166: 592-595
3. The Cochrane Collaboration <http://wwwsom.fmc.flinders.edu.au/FUSA/COCHRANE/>.
4. Sackett DL, Richardson WS, Rosenberg WR, Haynes RB. Evidence-based medicine: how to practice and teach EBM. New York: Churchill Livingstone, 1997: 2.
5. Jordens CFC, Hawe P, Irwig LM, et al. Use of systematic reviews of randomised trials by Australian neonatologists and obstetricians. Med J Aust 1998; 168: 267-270.
6. Young JM, Ward JEW. General practitioners' use of evidence databases. Med J Aust 1999; 170: 56-58.
7. McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998; 316: 361-365.
8. Glasziou PP. Applying the evidence to the individual. Evidence-Base Health Advice Workshop. Nov 4-5 Melbourne. Melbourne: The Menzies Foundation and National Health and Medical Research Council. 1998.
9. Jacobson LD, Edwards AGK, Granier SK, Butler CC. Evidence-based medicine and general practice. Br J Gen Pract 1997; 47: 449-452.
10. Fowler C. Evidence-based learning in general practice. Br J Gen Pract 1996; 46: 754-755.
11. Gupta L, Ward JE, Hayward RSA. Clinical practice guidelines in general practice: a national survey of recall attitude and impact. Med J Aust 1997; 166: 69-72.
12. Gupta L, Ward J, Hayward RSA. Future directions for clinical practice guidelines: needs, lead agencies and potential dissemination strategies identified by Australian general practitioners. Aust N Z J Public Health 1997; 21: 495-499.
13. Rubin GL, Frommer MS, Vincent N, Phillips PA. Disseminating and implementing the evidence. Evidence-base Health Advice Workshop. Nov 4-5 Melbourne. Melbourne: The Menzies Foundation and National Health and Medical Research Council. 1998.
14. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998; 317: 465-468.

©MJA 1998
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