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General practitioners' use of evidence databases

Jane M Young and Jeanette E Ward
Med J Aust 1999; 170 (2): 56-58.
Published online: 18 January 1999

Research

General practitioners' use of evidence databases

Jane M Young and Jeanette E Ward

MJA 1999; 170: 56-58
For editorial comment, see Van Der Weyden
 

Abstract Objective: To determine the awareness and use of the Cochrane Library and access to the Internet by general practitioners in New South Wales.
Design: Cross-sectional postal survey in September 1997.
Participants: 311 of 428 (73% response rate) randomly selected general practitioners in New South Wales.
Main outcome measures: Proportion of respondents with access to the Internet at home or at work; proportion of respondents aware of, with access to, and ever using the Cochrane Library; independent predictors of awareness of the Cochrane Library.
Results: 134 respondents (43%) had access to the Internet either at home or at work; 42 (14%) were "on line" at their workplace. Seventy (22%) were aware of the Cochrane Library, although only 20 (6%) had access to it and 13 (4%) had ever used it. Those in group practice and members of Divisions were independently more likely to be aware of the Cochrane Library.
Conclusions: As patient outcomes will improve with systematic implementation of evidence-based treatments, these low rates of access to useful evidence databases raise issues regarding the best ways to support general practitioners with information technology.


Introduction There has been increasing interest in the use by clinicians of evidence databases and other resources, such as systematic reviews, meta-analyses and evidence-based guidelines, as aids for clinical decision-making. The first report of Australian clinicians' use of evidence databases was recently published in the Journal.1 In that study, 72% of neonatologists and 44% of obstetricians reported using evidence databases, with higher rates of use among those familiar with computers.

Although lack of awareness of evidence databases does not preclude evidence-based practice,2 the inability of practitioners to access research findings readily at the time of decision-making is a major impediment to best practice.3Because of the breadth of their work, general practitioners have diverse needs for evidence to inform their practice.4 Accessible evidence databases potentially represent an essential resource to meet these needs. The Cochrane Library, which includes the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness (Box 1), is recognised as one of the best resources for evidence. General practitioners can use it on CD-ROM or through the Internet.

Research from other countries suggests that general practitioners are reluctant to embrace information technology to support evidence-based clinical decision-making. Two recent surveys both reported that, at most, 40% of British general practitioners were aware of the Cochrane Database of Systematic Reviews.5,6 Furthermore, despite positive attitudes towards evidence-based medicine, general practitioners reported low levels of use of either printed or electronic summaries of evidence, even among those who were aware of these resources.6

In 1995, it was reported that a quarter of a national random sample of Australian general practitioners had access to a computer with a modem but less than 10% had access to the Internet.7 No reports have been published more recently to assess the uptake of information technology by general practitioners. The aim of our study was to determine New South Wales general practitioners' current awareness of, access to, and use of the Cochrane Library, and their access to the Internet both at home and at work.

Methods
Survey content and administration We added the following questions to a statewide random postal survey of general practitioners in NSW conducted in September 1997:
  • Are you aware of the Cochrane Library?
  • Do you have access to the Cochrane Library?
  • Have you ever used the Cochrane Library?
  • Do you have access to the Internet at your practice?
  • Do you have access to the Internet at home?

Respondents could indicate "Yes", "No" or "Unsure" to each of these questions. Respondents also completed eight standard sociodemographic questions. A copy of the questionnaire is available from the authors on request.

Four hundred and twenty-eight eligible general practitioners in NSW, randomly selected from a commercial list, were contacted by telephone in advance of our survey. Two mail reminders and a telephone prompt were used to maximise the response rate.  

Data analysis Proportions and 95% confidence intervals were calculated for responses to questions about the Cochrane Library and Internet. The univariate association between awareness of and access to the Cochrane Library and personal and professional characteristics of respondents were assessed using c2 tests, or Fisher's exact test where expected cell frequencies were less than five. Logistic regression using a backwards stepwise modelling strategy was then carried out to identify factors that significantly and independently predicted positive responses to these questions. All analyses were conducted using SAS for Windows.8 

Ethics approval This study was approved by the Central Sydney Area Health Service Ethics Review Committee and the Human Ethics Committee of Sydney University.

Results
We received completed questionnaires from 311 general practitioners (73% response rate). Although the response rate for women (80%) was significantly higher than for men (70%) (chi-squared = 4.5; df = 1; P = 0.03), respondent characteristics were similar to those of general practitioners in NSW.9 Respondents ranged in age from 24 to 72 years (mean, 45 years), 96 (31%) were women, 236 (76%) worked full time, and 202 (65%) were in group practice. Professional characteristics of respondents included RACGP affiliation (141; 45%), AMA membership (109; 35%), and membership of a Division of General Practice (242; 78%). A third of respondents (107; 34%) had trained with the Family Medicine Program.

Responses to the questions about the Cochrane Library and Internet are shown in Box 2. Less than a quarter of respondents were aware of the Cochrane Library and only 13 (4%) had used it. Nearly one in five respondents were unsure if they had access to this resource. One hundred and thirty-four respondents (43%) had access to the Internet either at home or work, significantly higher than the 9% reported previously (chi-squared = 86.6; df = 1; P < 0.001).7

Box 2

Awareness of the Cochrane Library was unrelated to age (t = -1.1; df = 298; P = 0.2) or sex (chi-squared = 0.6; df = 1; P = 0.4). The only significant associations were with general practice Divisional membership and working in group practice. These variables remained independently predictive of awareness of the Cochrane Library following logistic regression analysis (Box 3). The number of respondents who had actually used the Cochrane Library were too few for further analysis.

Box 3

Discussion
Overall, 22% of respondents were aware of the Cochrane Library. As awareness was greater among those in group practice and members of their local Division, peer contact appears to be an important mechanism to promote evidence databases. Nonetheless, the level of awareness in our study was considerably lower than that reported in the United Kingdom,5,6 where the Cochrane Database of Systematic Reviews has been available since 1992.10 However, our finding that only 4% of respondents had ever used the Cochrane Library is comparable.

Our finding of a marked uptake since 1995 of Internet access by general practitioners is reassuring. Nearly half had Internet access either at home or at their practice. However, only 14% were "on-line" at their practices, where clinical decisions are likely to be made. Evaluation of strategies to support the uptake of information technology for desktop Internet access will be an immediate challenge in ensuring evidence databases are used in general practice.

Access to evidence databases is crucial to support the scientific paradigm now advocated in healthcare.11 Having accessed an evidence database, general practitioners can focus on treatments for which there is Level I (meta-analysis of randomised controlled trials) or Level II (randomised controlled trials) evidence of effectiveness. By ensuring treatments with such compelling evidence are used, GPs can confidently anticipate that their patient outcomes will positively and predictably improve. Less confidence can be placed on interventions for which only Level IV (descriptive case reports) evidence exists. Measurement and improvement of care based on Level I or II evidence of effectiveness should also be emphasised in quality assurance activities.12

Three years ago it was argued that "the health care system needs an infrastructure for the dissemination of evidence-based medicine into clinical practice".13 Subsequently, some people have suggested that general practitioners need mediated search services.14 Other problems to overcome include training general practitioners to appraise evidence4 and to incorporate research findings into their daily consultations with patients.15 Our findings suggest we have a long road ahead. Since June 1998, members of the Royal Australian College of General Practitioners (RACGP) have had access to the Cochrane Library through the RACGP Virtual Resource Centre. Evaluation of the impact of electronic evidence resources, including evidence databases or Web-based guidelines, on decision-making in general practice is the next step.

Initiatives to encourage evidence-based decision-making in general practice are likely to generate dissatisfaction with the limitations of currently available evidence.16 We are optimistic this will accelerate the quality and quantity of research conducted in general practice. Syntheses of current knowledge prevent the reinvention of wheels or repetition of past mistakes, minimising expenditure on populist strategies without strong evidence of effectiveness. Gaps in current knowledge of effective interventions in clinical practice are tellingly revealed in evidence databases, inviting a responsive academic research agenda. General practitioners adopting an evidence-based approach may be more inclined to participate in research which is relevant, rigorous and responsive to gaps in evidence sorely felt in clinical decision-making.

Acknowledgements
The participation of general practitioners in our research, without financial incentive, is acknowledged gratefully. We thank Nancy Harding for organisational support and Leonie Cambage for data entry. J M Y is supported by an NHMRC research scholarship.

References
  1. 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.
  2. Phillips PA. Disseminating and applying best evidence. Med J Aust 1998; 168: 260-261.
  3. Haines A, Jones R. Implementing findings of research. BMJ 1994; 308: 1488-1492.
  4. Ridsdale L. Evidence-based learning for general practice. Br J Gen Pract 1996; 46: 503-504.
  5. Prescott K, Lloyd M, Douglas HD, et al. Promoting clinically effective practice: general practitioners' awareness of sources of research evidence. Fam Pract 1997; 14: 320-323.
  6. 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.
  7. 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.
  8. SAS for Windows [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995.
  9. Commonwealth Department of Health and Family Services. General practice in Australia: 1996. Canberra: Commonwealth of Australia, 1996.
  10. Silagy C. Randomised controlled trials: the challenge of Archie Cochrane. Med J Aust 1993; 158: 656-657.
  11. Risdale L. How do you know? The process of scientific reasoning. In: Evidence-based general practice: a critical reader. London: WB Saunders, 1995; 160-169.
  12. Ward J, Del Mar C, Colmer P, O'Connell D. Quality and outcomes in general practice. In: General practice in Australia: 1996. Canberra: Commonwealth of Australia, 1996; 169-199.
  13. Ahmed T, Silagy C. The move towards evidence-based medicine. Med J Aust 1995; 163: 60-61.
  14. Fowler C. Evidence-based learning in general practice. Br J Gen Pract 1996; 46: 754-755.
  15. Jacobson LD, Edwards AGK, Granier SK, Butler CC. Evidence-based medicine and general practice. Br J Gen Pract 1997; 47: 449-452.
  16. Campion-Smith C. Evidence-based general practice. Br J Gen Pract 1997; 47: 462.

(Received 18 May, accepted 15 Sep, 1998)

Authors' details
Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Newtown, NSW.
Jane M Young, MB BS, MPH, Postgraduate Fellow;
Jeanette E Ward, PhD, FAFPHM, Director.

Reprints: Associate Professor J E Ward, Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Locked Bag 8, Newtown, NSW 2042.
Email: jwardATnah.rpa.cs.nsw.gov.au


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Received 18 November 2018, accepted 18 November 2018

  • Jane M Young
  • Jeanette E Ward


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