Original article 121

Clinicians’ self-perceived competency in evidence-based practice at Zagazig University Hospitals, Egypt Eman M. Mortada Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt Correspondence to Eman M. Mortada, Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt Tel: + 20 109 686 5168; e-mail: [email protected]

Received 15 May 2013 Accepted 17 September 2013 Journal of the Egyptian Public Health Association 2013, 88:121–129

Background and aim Evidence-based medical practice has gained worldwide attention and is an emerging must-know topic for today’s physicians. Yet, it continues to puzzle physicians either in its understanding or in its practice, and gaps continue to exist between researchbased evidence and clinical practice. This study aimed to evaluate the self perceived EBM competency of the clinicians and staff of Zagazig University Hospital. Study design and participants A cross-sectional study was carried out on a sample of 184 clinicians during the period of March–July 2012 at five randomly chosen special medicine departments (tropical medicine, rheumatology, neurology, dermatology, and hematology–oncology) using a self-administered, specifically tailored questionnaire. Results Sampled clinicians were dichotomized according to their self-reported frequency of evidence-based practice into evidence-based medicine (EBM) nonusers (62.5%) and EBM users (37.5%). There was no significant difference between users and nonusers in total mean scores (21.37 ± 1.86 vs. 21.34 ± 2.2, P = 0.119). Users had significantly higher mean score for self-perceived EBM competency compared with nonusers (P = 0.000), although both users and nonusers had unsatisfactory mean score for EBM competency (38.33 ± 2.87 vs. 32.96 ± 3.026, respectively) (median, 39 vs. 33, respectively). Users of EBM had a significantly higher score in competencies related to the use of a bibliographic database, understanding of methodological terminology, confidence in their skills in EBM steps, and consequently in cumulative EBM competency (P = 0.000). Conclusion and recommendations Our findings support some important facts: first, there is discrepancy between clinicians’ perceptions and their competency, as they considered themselves practicing EBM although they were not; second, strategies to promote a change in clinical practice are more likely to be successful if they are based on an analysis of problems. All findings in this study highlighted the importance of training in EBM. Keywords: competency, evidence-based medical practice, self-perceived, self-reported J Egypt Public Health Assoc 88:121–129 & 2013 Egyptian Public Health Association 0013-2446

Introduction Evidence-based medical practice (EBMP) has gained worldwide prominence. It is a newly emerging area of expertise and considered a core clinical competence in the 21st century to the extent that all physicians are increasingly required to remain up to date in contemporary practices [1]. Medical sciences are continuously evolving, as new diseases, new techniques, and new methods are constantly emerging. There is information revolution in medicine, which is known as the ‘basic leap from bedside to computer’ [2]. This phenomenon has provided an appropriate environment for the development of evidence-based medicine (EBM). Physicians are therefore required to continuously adjust their skills in line with the developments in medical science to prevent a gap in 0013-2446 & 2013 Egyptian Public Health Association

knowledge occurring between the theories taught while they were in university and those used in clinical practice at present [3]. As EBM is concerned with the application of diagnostic, therapeutic, and prognostic technologies in day-to-day management of patients [4], practicing EBM means ‘a problem-solving approach to clinical practice that integrates important aspects: current best evidence, clinical expertise, and patients’ values’ [5]. Clinical expertise refers to the health professional’s clinical skills and past experience in identifying and treating each patient on the basis of the patient’s individual condition. Patient values include personal concerns, expectations, cultural influences, and individual characteristics [5]. The best evidence draws on the highest quality of clinically related research. The integration of these three elements increases the potential for positive health outcomes [6]. DOI: 10.1097/01.EPX.0000436478.40699.a5

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122 Journal of the Egyptian Public Health Association

Competency in EBMP provides clinicians with the ability to effectively practice EBM and fully integrate EBM into clinical practice. Physicians need skills such as the ability to formulate a clinical question, search for the best available evidence, critically appraise the evidence, and apply the evidence to the individual patient [7]. EBM depends primarily on physicians’ ability to critically appraise the validity of research evidence and successfully incorporate it into patient care [8]. To do so, physicians must first have good knowledge and understanding of research methodology and data analysis [9]. EBMP has been associated with several benefits. It promotes the identification of the best methods of healthcare and helps both patients and physicians make better choices [10]. It is a generally accepted means to improve healthcare quality through the standardization of medical care by ensuring that the right treatment is given to the right patient. The use of evidence-based practice (EBP) helps prevent practices that are unsafe or lack empirical support, reduce unacceptable individual variance, reduce uncertainty in medical practice, and ultimately increase the efficiency and quality of healthcare [11]. Despite these benefits, barriers to EBMP still exist, complicating its implementation. In internal medicine, for example, a study conducted in Japan and Indonesia (2012) revealed that only about half of all medical treatments are evidence-based [3]. The main problems to practicing EBM are related to lack of time to access the EBM source, lack of methodological competence needed to make sound judgments about research quality, insufficient knowledge of and inadequate competencies in research methods, and the attitude of the physician themselves [12–14]. If progress has to be made toward empowerment of the professions, it is imperative that the various barriers to EBM implementation be identified in order to achieve success [15].

Objectives The objectives of the study were as follows: (1) To measure clinicians’ perceived competency with respect to the main steps of EBM. (2) To determine the relationship between their selfreported EBP and their competence. (3) To explore their opinions about EBM. (4) To determine the perceived problems that interfere with the application of EBM in practice.

Participants and methods Study design and sampled participants

A cross-sectional study was carried out during the period of March–July 2012 at special medicine departments in Zagazig University Hospital. There are nine special medicine departments, from which only five departments were randomly chosen (tropical medicine, rheumatology, neurology, dermatology, and hematology–oncology). The

study was expected to have 80% statistical power to detect statistical significance at 95% confidence interval, and 16% of clinicians were classified as ‘EBM users’ on the basis of the finding from the pilot study. Thus, the required sample was 184 clinicians. Operational definitions

For the purpose of the study, competency has been defined as the ability to incorporate a variety of domains including knowledge, skills, and performance [16]. Competency in EBM has been operationally defined as competency in performing the steps of the evidencebased practice process, such as ask well-formulated questions, acquire best available research evidence, appraise evidence for quality and relevance, and apply the evidence to the individual patient [17]. Study tool

A self-administrated, specifically tailored questionnaire adapted from previously validated relevant study tools assessing self-perceptions and competence in EBM was used [3,18–21]. The initially developed questionnaire was tested on a sample of 15 physicians (they were not included in the final analysis) to estimate the sample size and evaluate the content validity, clarity, and applicability of the study tool. Thereafter, slight modifications according to the results of the pilot study were made to facilitate data collection. The final questionnaire was divided into several parts as follows: (1) The first part of the questionnaire was composed of questions about personal and professional characteristics. Personal characteristics included age, sex, and medical specialty. Professional data recorded were: the length of professional experience and qualifications, the number of patients examined per day, and whether they were involved in research activity or teaching in addition to providing patient care. We also asked whether they had received any training in browsing the Internet, in research methodology, and any formal training in EBM and asked whether they use EBM in their daily practice and to what extent. Response choices were: rarely, sometimes, often, and always. (2) The second part assessed clinicians’ opinion about EBM and included different statements on the controversial aspects of EBM, such as EBM devalues clinical experience, de-emphasizes history-taking and physical examination skills, is difficult to be applied in daily practice, or that it improves patient care, helps clinical decision making, should be taught to medical students, and evidence-based practice (EBP) helps reduce healthcare cost. Responses were measured using a five-point Likert scale, from strongly agree to strongly disagree, to assess eight opinion statements, which included positive and negative ones; for the negative statements, the score was reversed [21]. The total opinion score was calculated: total minimum score = 0 and total maximum score = 32.

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Clinicians’ self-perceived competency Mortada 123

(3) The third part of the questionnaire measured selfperceived EBP competency using questions that assessed the following: (a) Competence in the usage of an electronic bibliographic database related to EBM. Clinicians were asked to rate their competence in using a common bibliographic database relevant to EBM: sources offering preappraised evidence, such as American College of Physicians journal club, EBM journals, and Cochrane database of systematic reviews, and sources offering evidence from various study designs, such as TRIP (Turning Research into Evidence database), DARE (Database of Abstract Reviews of Effectiveness), and Medline journals. The answers were categorized and scored into four responses: 0, unaware; 1, aware but do not use; 2, read; and 3, have used in clinical decision making. The total minimum score was 0 and the total maximum score was 18. (b) Competence in understanding the methodological terminology used in EBM papers. It was assessed using 10 statistical terms commonly observed in research papers: relative risk, number needed to treat, systematic review, P-value, confidence interval, randomization, sensitivity, likelihood ratio, and metaanalysis. We also added one fictitious term (coincidence bias) to assess their actual understanding as was done in two previous studies [20,22]. Responses to each term were scored as follows: 1, do not understand but would like to; 2, some understanding; and 3, understand and could explain to others. The total score was then calculated, which ranged from 10 to 30. (c) Self-perceived confidence in the main steps of EBM. (i) The participants were asked to assess their confidence level at carrying out the four steps of EBM, such as the ability to formulate clinical questions using the PICO format (population, intervention, comparison, and outcome), ability to track down the best evidence that answers the formulated question, ability to critically appraise evidence, and ability to apply the evidence to patients. Responses were: little, good, very good, and perfect. Each item was scored as follows: 1, little; 2, good; 3, very good; and 4, perfect. A total maximum confidence score was calculated. The total score ranged between 4 and 16. (ii) The scoring results were then rated to generate a total cumulative score of EBM competency; total minimum score was 14 and total maximum score was 64. The median scores for the study population were calculated for all of the above calculated scores. Scoring results were presented using median as a cutoff point. Those who had a score above the median score were rated as having satisfactory

competency, whereas those who had a score equal to or below the median score were rated as having unsatisfactory competency. (d) Finally, it included questions that assessed the most common problems that interfere with application of EBM in clinical practice. A list of possible barriers was addressed, including lack of time to search EBM sources, insufficient EBM training, difficulty in changing the current practice model, influences of pharmaceutical companies, difficulty in keeping up to date because of fast-changing insights in the field of practice, patient preferences, resistance and criticism from colleagues, and difficulties in interpreting research results because of academic language. Responses were yes or no. Ethical consideration

All necessary approvals for carrying out the research were obtained, including approvals from the general manager of the hospital and the heads of the department in which we carried out the research. In addition, the purpose and importance of the research were discussed with clinicians. Implicit consent to participate in the study was obtained. The questionnaires were strictly confidential and anonymous, and each questionnaire was numerically coded. Statistical analysis

Sample size was calculated using Epi-info version 6 (District of Columbia, USA). Data were coded and statistically analyzed using the computerized software statistical package SPSS version 19 (SPSS Inc., Chicago, Illinois, USA) [23]. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and means and SDs for quantitative variables. The w2-test, the Mann–Whitney U-test, and the Student t-test were used for nonparametric data, whereas the independent t-test and Fisher’s exact test were used for parametric data. Odds ratio and confidence interval were used to quantify the associations. Multivariate analysis using stepwise logistic regression was used to determine the most important factors affecting EBM competency score. Statistical significance was considered at P-value less than 0.05. Box plot was used to present cumulative competency score, where the length of the box indicates the IQR, the line included in the box represents the median, and the whiskers represent the minimum and maximum values. A Pareto chart was created using Excel. Cronbach’s a was used to test the internal consistency of the questionnaire. Cronbach’s a of 0.7 is normally considered to indicate a reliable set of items [24].

Results The majority of the sampled clinicians (70.1%) reported that they incorporate EBM in their daily clinical practice. The proportion of clinicians reporting the use of EBM in their clinical practice were: 10.9% always, 26.6% often, 35.3% sometimes, and 27.2% rarely (Fig. 1). They were dichotomized according to self-reported frequency into

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124 Journal of the Egyptian Public Health Association

EBM users and EBM nonusers; clinicians who reported using EBM ‘sometimes’ or ‘rarely’ were considered as EBM nonusers (62.4%), whereas those who reported using EBM ‘always’ or ‘often’ were considered as EBM users (37.5%) (Fig. 2). Table 1 shows the characteristics of the studied sample. The use of EBM by male physicians and female physicians was nearly the same. However, male nonusers predominated (74.0%). The mean age was 37.85 ± 8.4 years and mean professional experience was 12.53 ± 7.78 years. Of the participating physicians, 30.4% were lecturers; 87.0% were not involved in patient care, although among them 59.4% were involved in teaching and 81.0% were involved in research. The only significant difference between users and nonusers of EBM was with respect to the age of respondent clinicians (P = 0.039); 53.0% of nonusers were younger than 35 years of age. This indicated that nonusers are more in number among young staff. With respect to the specialty of the sampled clinicians who reported using EBM, 27.5% were neurologists, 20.3% were tropical medicine specialists, 18.8% were rheumatologists, 18.0% were dermatologists, and 14.5% were oncologists. Table 1 also shows that the majority of the sampled clinicians (77.17%) had received training on research methodology, 57.08% had received a basic training in Internet browsing strategy as a prerequisite for their doctorate degree, and almost half (42.38%) of them had received formal training in EBM. There was a strong association between EBM training and EBM use, as those who received EBM training were about two times more likely to use EBM. Similarly, there was a strong association between research methodology Figure 1.

29.2 Incorporate EBM in their daily practice

Don’t incorporate EBM in their daily practice 70.8 Classification of the studied sample according to the incorporation of EBM into their daily practice.

Figure 2.

37.6

EBM non-user

EBM user

62.4

Classification of respondent clinicians according to their self-reported frequency of clinical practice that is currently evidence-based.

training and EBM use, as the use of EBM was two times more among those who had received training in EBM. The majority of clinicians (75.0%) were enthusiastic and had a desire to participate in EBM training courses, with no significant difference between users and nonusers; the majority of both groups (75.7 and 73.9%) desired to receive training in EBM (Table 2). Clinicians’ opinion on EBM is illustrated in Table 3. Clinicians had an unsatisfactory opinion score on EBM, as the mean opinion score was 21.35 ± 2.08 (median, 21). There was no significant difference between users and nonusers in total mean scores (21.37 ± 1.86 vs. 21.34 ± 2.2, P = 0.119). On comparing each statement, the highest positive statement score was given for the opinion that EBM improves patient outcome, and there was a significant difference between users and nonusers (3.73 ± 0.58 vs. 3.5 ± 0.6, P = 0.016). There were no significant differences in the remaining positive statements, as both users and nonusers agreed that EBM should be taught in medical school, helps in clinical decision making, and can reduce healthcare costs (P40.05). There were significant differences between both groups with respect to negative statements on EBM. Nonusers’ scores were significantly higher than those of users, and they believed that EBM devalues clinical experience, de-emphasizes history-taking, and its application is difficult in daily practice (Pr0.05). The internal consistency for opinion statements was acceptable (Cronbach’s a: 0.74). Table 4 shows the clinicians self-perceived familiarity and use of bibliographic databases according to their usage of EBM. It revealed that users had a satisfactory overall database familiarity with a mean score of 12.25 ± 1.3 and a median of 12, whereas nonusers showed an unsatisfactory level in their usage of databases with a mean score of 9.59 ± 1.78 and median of 10; the difference was highly significant (P = 0.000). The most commonly used resources by the users were the Cochrane database and EBM journal (52.2 and 49.3%), whereas nonusers stated that they only read them. Other resources were not used; however, the majority of users reported that they read them, whereas nonusers reported only being aware of them but did not read them. There was no significant difference between users and nonusers with respect to their reported usage of Medline journals, and both groups read them and used them in clinical decision making. Cronbach’s a for database usage was 0.81; hence, internal consistency for database usage was acceptable. Table 5 revealed that users attained higher scores in understanding most of the terminologies commonly used in research literature. P-value was the best understood term by users as was reflected by its mean score (2.65 ± 0.47), and 65.2% of users reported that they could understand and explain it to others. Similarly, users had higher scores than nonusers in understanding and explaining relative risk and randomization (P = 0.00 and 0.013, respectively). The least understood terms were meta-analysis, systematic review, number needed to treat, and likelihood ratio. There was no significant difference between users and nonusers (P40.05). The

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Clinicians’ self-perceived competency Mortada 125

Table 1. Characteristics of the studied sample according to their self-reported usage of evidence-based medicine in daily practice (n = 184) Variables Sex Age groups X ± SD Academic rank

Experience (years) X ± SD Specialty**

Number of patients examined/day Patient care only Teaching Current research

Category

EBM nonuser (n = 115) [n (%)]

EBM user (n = 69) [n (%)]

P-value

74 (64.3) 41 (35.7) 61 (53.0) 42 (36.5) 12 (10.4) 35.5 ± 6.9 7 (6.1) 30 (26.1) 49 (42.6) 18 (15.7) 11 (9.6) 61 (53.0) 40 (34.8) 14 (12.2) 10.33 ± 6.38 26 (22.6) 24 (20.9) 20 (17.4) 25 (21.7) 20 (17.4) 75 (65.2) 40 (34.8) 92 (80.0) 23 (20.0) 54 (47.0) 61 (53.0) 21 (18.3) 94 (81.7)

35 (50.7) 34 (49.3) 31 (44.9) 21 (30.4) 17 (24.6) 37.85 ± 8.4 5 (7.2) 16 (23.2) 21 (30.4) 13 (18.8) 14 (20.3) 31 (44.9) 22 (31.9) 16 (23.2) 12.52 ± 7.78 16 (20.3) 10 (14.5) 13 (18.8) 19 (27.5) 13 (18.0) 36 (52.2) 33 (47.8) 60 (87.0) 9 (13.0) 28 (40.6) 41 (59.4) 14 (19.0) 55 (81.0)

0.088

Male (n = 109) Female (n = 75) o35 (n = 92) 35–44 (n = 63) Z45 (n = 29) Resident (n = 12) Assistant lecturer (n = 46) Lecturer (n = 70) Assistant professor (n = 31) Professor (n = 25) o10 (n = 92) 10–19 (n = 62) Z20 (n = 30) Tropical medicine (n = 40) Oncology (n = 34) Rheumatology (n = 33) Neurology (n = 44) Dermatology (n = 33) o20 (n = 111) Z20 (n = 73) No (n = 152) Yes (n = 32) No (n = 82) Yes (n = 102) No (n = 35) Yes (n = 149)

0.039*

0.215#

0.156

0.186

0.08 0.276 0.445 0.846

EBM, evidence-based medicine. *Significance difference (Pr0.05). **Fisher exact test used in the variable speciality. # Fisher’s exact test is used. Table 2. Training of clinicians according to their usage of evidence-based medicine in daily practice (n = 184) Variables Previous training in EBM Research methodology Internet search strategy Desire for EBM training

Category No (n = 106) Yes (n = 78) No (n = 42) Yes (n = 142) No (n = 80) Yes (n = 104) No (n = 46) Yes (n = 138)

EBM nonuser (115) [n (%)] 74 41 32 83 47 68 28 87

(64.3) (35.7) (27.8) (72.2) (40.9) (59.1) (24.3) (75.7)

EBM user (69) [n (%)] 32 37 10 59 33 36 18 51

(46.4) (53.6) (14.5) (85.5) (47.8) (52.2) (26.1) (73.9)

OR (CI) 2.08 (1.13–3.83)* 2.27 (1.038–4.98)* 0.75 (0.413–1.37) 0.912 (0.46–1.81)

CI, confidence interval; EBM, evidence-based medicine; OR, odds ratio. *Significance difference (Pr0.05).

Table 3. Clinicians’ opinion on evidence-based medicine according to their usage of evidence-based medicine Opinion statements EBM devalues clinical experience (–) EBM de-emphasizes history taking (–) EBM is impractical for clinical practice (–) EBM application is difficult in daily practice (–) EBM should be taught in medical school (+) EBM improves patient outcome (+) EBM helps clinical decision making (+) EBM practice can reduce healthcare costs (+) Average opinion score Total score

EBM nonuser (X ± SD) 2.52 ± 0.8 2.30 ± 0.67 2.02 ± 0.8 2.42 ± 0.67 2.86 ± 0.57 3.5 ± 0.6 2.78 ± 0.59 2.93 ± 0.65 21.34 ± 2.2

EBM user (X ± SD) 2.32 ± 0.9 1.80 ± 0.51 2.03 ± 0.7 1.78 ± 0.56 3.76 ± 0.46 3.73 ± 0.58 2.85 ± 0.69 2.95 ± 0.72 21.37 ± 1.86 21.35 ± 2.08 (median = 21)

P-value 0.05* 0.009* 0.145 0.005* 0.573 0.016* 0.223 0.281 0.119

EBM, evidence-based medicine. (–) Statements have been reversely coded. ( + ) Positively scored sentences. *Significance difference (Pr0.05).

majority of both groups stated that they either do not understand the terms or understand them to some extent. There was no difference in understanding the

fictitious term (coincidence bias) between users and nonusers (P = 0.28), and the majority of the two groups (75.4 and 67.8%) reported that they do not understand

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126 Journal of the Egyptian Public Health Association

Table 4. Self-perceived familiarity and use of bibliographic databases among sampled clinicians according to their usage of evidence-based medicine Bibliographic database

Unaware

Aware but not used

Read

Useda

X ± SD

P-value

30 (26.1) 34 (49.3)

1.86 ± 0.9 2.4 ± 0.64

0.000*

7 (6.1) 36 (52.2)

1.72 ± 0.58 2.43 ± 0.65

0.000*

0 (0.0) 3 (4.3)

1.11 ± 0.58 1.61 ± 0.59

0.000*

0 (0.0) 2 (2.9)

1.17 ± 0.50 1.53 ± 0.60

0.000*

0 (0.0) 14 (20.3)

1.41 ± 0.51 1.95 ± 0.69

0.000*

47 (40.93) 30 (43.5)

2.25 ± 0.73 2.33 ± 0.65

0.392

b

EBM journal EBM nonuser 10 (8.7) 25 (21.7) 50 (43.5) EBM user 0 (0.0) 6 (8.7) 29 (42.0) Cochrane database of systematic reviewb EBM nonuser 1 (0.9) 37 (32.2) 70 (60.9) EBM user 0 (0.0) 6 (8.7) 27 (39.1) American College of Physicians (ACP) journal clubb EBM nonuser 14 (12.2) 74 (64.3) 27 (23.5) EBM user 1 (1.4) 27 (39.1) 38 (55.1) b Turning Research Into Evidence (TRIP) database EBM nonuser 6 (5.2) 83 (72.2) 26 (22.6) EBM user 2 (2.9) 30 (43.5) 35 (50.7) b Database of Abstract Reviews of Effectiveness (DARE) EBM nonuser 1 (0.9) 64 (55.7) 50 (43.5) EBM user 1 (1.5) 15 (21.7) 39 (56.5) Medline EBM nonuser 0 (0.0) 21 (18.3) 47 (40.9) EBM user 0 (0.0) 6 (9.0) 31 (46.3) Overall mean score EBM nonuser Median = 10, range (5–14) EBM user Median = 12, range (10–15)

9.53 ± 1.78 12.28 ± 1.3

0.000*

EBM, evidence-based medicine. Used in clinical decision making. b The Mann–Whitney U-test is used to test statistical significance. *Significance difference (Pr0.05). a

Table 5. Self-perceived understanding of evidence-based medical terminology among clinicians according to their usage of evidence-based medicine Confidence in EBM steps

Does not understand

Some understanding

Understand and explain

X ± SD

P-value

21 (18.3) 12 (17.4)

86 (74.8) 38 (55.1)

8 (7.0) 19 (27.5)

1.88 ± 0.48 2.10 ± 0.66

0.013*

24 (20.9) 13 (18.8)

77 (67.0) 47 (68.1)

14 (12.2) 9 (13.0)

1.91 ± 0.57 1.94 ± 0.56

0.738

42 (34.8) 11 (15.9)

72 (62.6) 40 (58.0)

3 (2.6) 18 (26.1)

1.67 ± 0.52 2.10 ± 0.64

0.000

69 (60.0) 40 (58.0)

38 (33.0) 20 (29.0)

8 (7.0) 9 (13.0)

1.46 ± 0.62 1.55 ± 0.71

0.422

15 (13.0) 0 (0.0)

83 (72.2) 24 (34.8)

17 (14.8) 45 (65.2)

2.01 ± 0.52 2.65 ± 0.47

0.000*

20 (17.4) 11 (15.9)

85 (73.9) 45 (65.2)

10 (8.7) 13 (18.8)

1.9 ± 0.57 2.03 ± 0.68

0.16

22 (19.1) 9 (13.0)

57 (49.6) 31 (44.9)

36 (31.3) 29 (42.0)

2.12 ± 0.70 2.28 ± 0.68

0.115

71 (61.7) 48 (69.6)

44 (38.3) 21 (30.4)

0 (0.0) 0 (0.0)

1.38 ± 0.48 1.30 ± 0.46

0.285

27 (23.5) 17 (24.6)

61 (53.0) 40 (58.0)

27 (23.5) 12 (17.4)

2.00 ± 0.68 1.9 ± 0.64

0.481

78 (67.8) 52 (75.4)

37 (32.2) 17 (24.6)

0 (0.0) 0 (0.0)

1.32 ± 0.46 1.25 ± 0.43

0.280

17.70 ± 1.79 19.1 ± 1.9

0.000*

Relative risk EBM nonuser EBM user Number needed to treat EBM nonuser EBM user Meta-analysis EBM nonuser EBM user Systematic review EBM nonuser EBM user P-value EBM nonuser EBM user Confidence interval EBM nonuser EBM user Sensitivity EBM nonuser EBM user Likelihood ratio EBM nonuser EBM user Randomization EBM nonuser EBM user Coincidence biasa EBM nonuser EBM user Overall mean score EBM nonuser EBM user

Median = 18 range (14–23) Median = 19 range (14–24)

EBM, evidence-based medicine. Fictitious term. *Significance difference (Pr0.05). a

the term. In general, users have significantly higher overall mean score for self-perceived terminology understanding compared with nonusers (P = 0.000). Users had a satisfactory mean score (19.14 ± 1.92), whereas non-

users had an unsatisfactory mean score (17.70 ± 1.79) in their understanding of terminology (median was 18). This part of the questionnaire had a high degree of internal consistency (Cronbach’s a was 0.87).

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Clinicians’ self-perceived competency Mortada 127

When self-perceived confidence in the main steps of EBM was assessed we found that, although users had a significantly higher self-perceived confidence mean score compared with nonusers (P = 0.000), both users and nonusers had an unsatisfactory self-perceived confidence mean score (6.89 ± 1. 27 vs. 5.73 ± 1.27) (median 7 vs. 6, respectively) (Table 5). Analysis of self-confidence scores for each EBM step revealed that the highest score for EBM users was in their ability to search for evidence (2.43 ± 0.49), as they described their ability to be very good or perfect (56.5 and 43.5%, respectively). Similarly, users scored higher than nonusers with respect to their ability to formulate PICO question (P = 0.000), and a high proportion of them reported being good or very good (46.3 and 40.3%, respectively). Internal consistency of confidence in the main steps of EBM was acceptable, as Cronbach’s a was 0.75. After adding up all previously calculated scores to give an estimate of cumulative EBM competency score we found that, although users had significantly higher self-perceived cumulative EBM competency mean score compared with nonusers (P = 0.000), both users and nonusers had un-

satisfactory EBM competency mean scores (38.33 ± 2.87 vs. 32.9 ± 3.02, median was 39 vs. 33, respectively) as shown by box plot (Fig. 3). Table 6 revealed that on using multiple logistic regressions to determine predictors of EBM competency scores among sampled clinicians it was found that previous EBM training, research methodology training, and academic rank were significant predictors of EBM competency (P = 0.000, 0.008, and 0.047, respectively). Figure 4 shows the Pareto chart on how to solve the majority of encountered problems. Training the clinicians and equipping them with the needed skills and motivating the staff to change the current practice will solve 80% of the problems. However, lack of time is subject to individual variation.

Discussion EBM is becoming an important part of medical practice, and it is recommended that every physician base his decision on the evidence accruing from clinical research,

Figure 3.

frequency

cummulative percentage

180 160 140 120 100 80 60 40 20 0

80% marker 120% 100% 80% 60% 40% 20%

cumulative frequency

frequency

Cumulative EBM competency score

Figure 4. 50 45 40 35 30 25 20 15 10 5 0

0%

EBM non EBM users users Self reported usage of EBM

Cumulative EBM competency score among responding clinicians according to their self-reported usage of EBM.

Pareto chart for ranking the perceived problems that decrease incorporation of EBM into clinical practice.

Table 6. Self-perceived confidence in evidence-based medical steps among clinicians according to their usage of evidence-based medicine Confidence in EBM steps Ability to formulate PICO question EBM nonuser EBM user Ability to search for evidence EBM nonuser EBM user Critical appraisal ability EBM nonuser EBM user Apply evidence to your patients EBM nonuser EBM user Overall mean score EBM nonuser EBM user

Little

Good

Very good

Perfect

X ± SD

P-value

1 (9.0) 1 (1.4)

95 (82.6) 31 (46.4)

16 (13.9) 28 (40.6)

3 (2.6) 8 (11.6)

1.18 ± 0.46 1.63 ± 0.7

0.000*

0 (0.0) 0 (0.0)

34 (29.6) 0 (0.0)

81 (70.4) 39 (56.5)

0 (0.0) 30 (43.5)

1.70 ± 0.45 2.43 ± 0.49

0.000*

0 (0.0) 0 (0.0)

60 (52.2) 40 (58.0)

53 (46.1) 28 (40.6)

2 (1.7) 1 (1.4)

1.49 ± 0.53 1.43 ± 0.52

0.446

3 (2.6) 1 (1.4)

75 (67.6) 43 (62.3)

25 (22.5) 21 (30.4)

9 (8.1) 4 (5.8)

1.34 ± 0.66 1.40 ± 0.62

0.401

5.7 ± 1.27 6.8 ± 1.27

0.000*

Median = 6 range (3–11) Median = 7 range (5–11)

EBM, evidence-based medicine; PICO, population, intervention, comparison, and outcome. *Significance difference (Pr0.05).

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128 Journal of the Egyptian Public Health Association

which undergoes many refining processes to be valid for decision making. The present study revealed that, although the majority of sampled clinicians reported that they incorporate EBM in their daily practice, more than half (62.5%) were classified as nonusers when they were dichotomized according to self-reported frequency into EBM users and nonusers [25]. This finding is in agreement with previous studies [24–26], which reported that clinicians considered themselves to be practicing EBM but in fact they were not. This can be explained by the desire to be socially accepted and maintain the higher social status that clinicians perceive themselves to have. The only significant difference between users and nonusers of EBM was with respect to the age of respondent clinicians, as the highest proportion of nonusers were younger than 35 years. This finding is inconsistent with that of another research in Puerte Rico, which reported more EBM use by younger less-experienced age groups [26]. The majority of the sampled clinicians attended courses on research methodology and search strategy, as these topics became a part of the basic curriculum for a Doctoral degree only recently. On comparing the difference in history of previous training between users and nonusers, a strong association was found between EBM training and EBM use, and our findings were similar to those of other studies [24,27–30] that showed that, although training in EBM was received only by a small proportion of clinicians, this helped them to be more frequent users (twice as others). Similarly, research methodology courses were twice as common among users than among nonusers. The majority of clinicians were enthusiastic when asked whether they will participate in EBM training courses. This could be explained by the fact that training courses in EBM are still limited, as it is a relatively new concept. Both users and nonusers had unsatisfactory mean opinion scores on EBM, with no significant difference between them, as both agreed that EBM should be taught in medical school, helps clinical decision making, and can reduce healthcare costs. This was in agreement with the study by Mc Alister et al. [13] who found that the vast majority of both users and nonusers felt that EBM helps in clinical decision making. However, our findings were contradictory to other studies indicating that the majority of sampled physicians had satisfactory and extremely favorable opinions toward EBM [21,26]. This difference could be explained by the fact that in our country EBM is a new discipline and therefore the sampled clinicians have not yet formed a satisfactory opinion about it. To assess clinicians’ EBM competencies, we evaluated their self-rated knowledge, skills, and practices, such as familiarity and use of electronic EBM sources, understanding of methodological terminology, and their confidence in EBM steps. When self-assessing their familiarity and usage of different bibliographic resources, users reported significantly higher scores compared with nonusers and their scores were satisfactory compared with those of nonusers (Table 4) (P = 0.000). The most

commonly used resources in clinical decision making by users were the Cochrane database and the EBM journals. Our findings are in agreement with those of previous studies that reported that the most popular EBM resources were the Cochrane collaboration, and PubMed was the most accessed. Other sources were not used [19,26,30,31]. However, our findings are inconsistent with those of a study carried out in Ain Shams University, which reported that 30.7% of physicians in the medicine department used PubMed, and only 4.3% of respondents had ever used the Cochrane Database of Systematic Reviews [30]. Understanding of technical terms used in EBM is very essential because interpretation of evidence is a key element in practicing EBM, and misunderstanding of EBM terms could hinder interpretation and make cascading of evidence more difficult [18]. In our study, users have significantly higher overall mean score in self-perceived terminology understanding compared with nonusers (P = 0.000), and this score was satisfactory compared with the nonusers’ score (Table 4). These findings are similar to those of previous studies examining doctors’ perceptions of their own comprehension of EBM [19,20,24]. It is worth mentioning that, in the present study as well as in similar previous ones, answers to questions on EBM knowledge did not reflect the actual knowledge but perceived knowledge, which could be biased. Thus, actual knowledge of these terms may be poorer than was reported. On studying self-perceived confidence in the main steps of EBM we found that our result is in agreement with that of a previous study [24], as we found that the mean score of both groups was unsatisfactory, although users had significantly higher mean score for self-perceived cumulative competency compared with nonusers (P = 0.000). The highest score for EBM users was in their ability to search for evidence followed by their ability to formulate PICO question. In the present study, both users and nonusers had unsatisfactory EBM competency mean scores, although users had significantly higher mean score for self-perceived cumulative EBM competency compared with nonusers (P = 0.000). This is in contrast to the study by Buscalgia et al. [21] in Belgium, who reported that participants had more than satisfactory EBM competency score. This difference can be related to the duration of EBM practice, as Buscalgia et al. [21] found that most gastroenterologists admit to using EBM skills in their day-to-day decisions on medical therapy, which helped them achieve higher scores. Using multiple logistic regressions, our study revealed that previous EBM training, research methodology training, and academic rank were significant predictors of EBM competency (P = 0.000, 0.008, and 0.047, respectively). This reflects the importance of training courses in improving EBMP research methodology and EBM. Training the clinicians and equipping them with the needed skills, motivating the staff to change current practice, and integration of EBM into their daily clinical practice will solve 80% of the problems. Meanwhile, there could be alternatives to increasing the duration of EBM training [32]. This can be achieved by changing the emphasis of

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Clinicians’ self-perceived competency Mortada 129

postgraduate education from one-way lectures to training in accessing and interpreting evidence and then spending time in applying these skills to practical situations.

4 Sackett D, Haynes R, Guyatt G, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Boston/Toronto/London: Little, Brown; 1991. 5 Sackett D, Straus S, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone; 2002. 6 Gray JA. Evidence-based healthcare. How to make health policy and management decisions. London: Churchill Livingstone; 1997.

Conclusion and recommendations Our findings support some important facts: first, there is a discrepancy between clinicians’ perceptions and their practice, as they considered themselves practicing EBM but in fact they were not; second, strategies to promote change in clinical practice are more likely to be successful if they are based on an analysis of the problems. All findings in this study highlight the importance of training in EBM, as EBM competency tends to increase with training received in EBM and research methodology. Hence, we recommend the following: (1) Planning and implementing effective EBM educational programs for both undergraduate and postgraduate doctors can be useful. Our findings – such as opinion of clinicians about the value of using EBM journals as well as familiarity with the EBM and research methodology terms – should be taken into consideration when planning evidence-based practice, as it is important to tailor these programs to the needs of specific subgroups of trainees. (2) EBM should be integrated into the undergraduate curriculum not only in academic years but also in clinical years during clinical rotation. (3) EBM practical courses should be integrated into the residency program. (4) Senior clinicians should be motivated to become a role model for the younger generation in appreciating and utilizing EBM to improve clinical practice. (5) The EBM concept should be disseminated through workshops and seminars to help improve clinicians’ attitude. (6) Further studies are needed to determine the effect of educational intervention on clinicians’ practice and test whether and how EBMP affects the quality of the patient care processes.

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The author is grateful to the clinicians who participated in this study.

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Conflicts of interest

27 Veness M, Rikard-Bell G, Ward G. Views of Australian and New Zealand radiation oncologists and registrars about evidence-based medicine and their access to Internet based sources of evidence. Australas Radiol 2003; 47:409–415.

Acknowledgements

There are no conflicts of interest.

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Clinicians' self-perceived competency in evidence-based practice at Zagazig University Hospitals, Egypt.

Evidence-based medical practice has gained worldwide attention and is an emerging must-know topic for today's physicians. Yet, it continues to puzzle ...
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