General practitioners' use of evidence databases

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.

• 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.

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

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.

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.

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.

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

Make a comment

Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/>