Does Knowledge of evidence-based medicine help the implementation of Ophthalmological clinical practice guidelines?<br /> <br />Abstract<br />Background: CPGs are one of the time-saving and highest level of evidence for busy ophthalmologists to make the best clinical decision in a minimum possible time. The aim of study is evaluating Iranian ophthalmologists&rsquo; knowledge and attitudes toward EBM and comparing their potential knowledge about EBM with clinical practice. <br />Methods: A cross-sectional survey performed during the Annual Congress of Iranian Society of Ophthalmology. Two valid questionnaires about ophthalmologists&rsquo; attitudes toward EBM and self-reported clinical practice were administrated by randomly selected ophthalmologists. Chi-square or Fisher&rsquo;s Exact test were used to compare the qualitative variables and Spearman rank correlation coefficient was applied for correlation analysis.<br />Results: One-hundred ophthalmologists responded to the first questionnaire and 60% answered to the second questionnaire. Although 83% have heard about EBM but only 11% knew what EBM is. Ninety five percent of them believed in evidence based ophthalmology training. There was a small rate of EBM terminology understanding. More than 60% have no familiarity with Cochrane Library, MDconsult and TRIP. Of ophthalmologists, 26% implemented guidelines for problem-solving and 59% applied the Internet for finding clinical guidelines. The correct response rate for cataract and glaucoma questions was 67.61 and 55.55 respectively. There was a significant correlation between glaucoma and cataract questions&rsquo; mean scores (P=0.02).<br />Conclusion: According to the study, Iranian ophthalmologists had a fair knowledge and attitude toward EBM. Improving evidence based knowledge and attitude of them may improve their good clinical practice.<br /> <br />Introduction<br />Clinical decision making plays a major role in daily practice and the decisions are generally based on the physicians&rsquo; experience and knowledge, their consultation with colleagues, referring to textbooks or other components. Given that EBM means integrating individual clinical expertise with the best available evidence, one of the most important components in decision making could be familiarity with EBM. Therefore learning and understanding EBM will promote capabilities of clinicians and enables them to use the best evidence in decision making. However according to studies it seems that implementation of EBM among physicians of developing countries is still low and one of the most important reasons is unfamiliarity with concept of EBM and best evidence, in addition to lack of time especially among surgeons.<br />According to Oxford Center for EBM, information resources are located in five level of evidence; and since the CPG and their recommendations are generally developing based on high level of evidence, they are considered as one of the high quality and high level of evidence. As the Institute of Medicine (IOM) definition CPGs are &ldquo;systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances&rdquo;. Thus clinical practice guidelines play a major role in practice and even in policy making and in order to achieving desirable health outcomes it is needed to develop and implement CPGs.<br />Furthermore regarding that clinical guidelines are categorized as summaries in 5S pyramid of evidence resources which integrate best available evidence, they are an appropriate tool for busy clinicians to make a best decision based on guideline recommendations in a minimum possible time. Ophthalmologists are so busy just like most other surgeons and they have limited time to up-to-date themselves, therefore implementation of evidence based guidelines can lead them to best decision making.<br />There are limited studies in the rate of clinical guidelines implementation among ophthalmologists and it is not clear that if there is any relationship between evidence based knowledge and evidence based practice. The current study is designed to evaluate Iranian ophthalmologists&rsquo; knowledge and attitudes toward EBM and in addition comparing ophthalmologists&rsquo; potential knowledge about EBM with their self-reported clinical practice. <br /> <br />Methods<br />The study was a cross-sectional, questionnaire based survey performed during the Annual Congress of Iranian Society of Ophthalmology. According to the aims of study, two questionnaires were designed: The first questionnaire was self-administrated and developed based on a valid questionnaire in Persian language in which a couple of additional questions entered by authors and reliability and validity of the questionnaire was assessed properly.<br />The second questionnaire was developed by two experts in the field of ophthalmology and EBM. Clinical scenarios related to management of patients with cataract or glaucoma was designed based on best relevant evidence based clinical guidelines. The guidelines were searched for in clinical guideline databases including Pubmed, GIN, NGC, NICE, SIGN, WHO and other related websites.<br />Eventually, 13 scenarios selected after a group discussion and consensus of the authors and experts of ophthalmology department of Tabriz University of Medical Sciences. The questions selected in purpose of assessment of ophthalmologists&rsquo; attitude toward diagnosis and management of cataract and glaucoma. Ophthalmologists were asked to choose the best option regarding the scenario. Their performed options were compared with the best choice recommended by selected clinical guidelines.<br />All 556 attended ophthalmologists in the Annual Congress of Iranian Society of Ophthalmology invited to participate in this study. The aim of study explained to all of the participants and their interest into participation in the study considered as informed consent. Participants were asked to fulfill the first questionnaire and then the second questionnaire was administrated by them. All personal information kept confidential.<br />Descriptive statistics were obtained for all parts of the questionnaire using Excel 2010. The data was analyzed using SPSS 16. Chi-square (&chi;2) or Fisher&rsquo;s Exact test were used to compare the qualitative variables and Spearman rank correlation coefficient was applied for correlation analysis. P value less than 0.05 was considered significant.<br /> <br />Results<br />One hundred out of 556 ophthalmologists returned the first questionnaire whiles sixty (60%) of them answered the questions of second questionnaire. Fifty five (55%) of respondents were male and 45 were female. Thirty two (34.8%) of them were younger than 40, 33 (35.9%) were 41-50 years old and 27 (29.3%) were older than 50 years old. More than half of respondents (54.3%) had more than 15 years&rsquo; experience in ophthalmology (Fig 1). Proportion of participants in each of faculty members, health system employees and non-faculty groups were equal and nearly one third. <br /> <br /> <br />Of one hundred respondents, 83 (83%) have heard about EBM and 11 (11%) knew what EBM is. Ninety five (95%) of them believed that ophthalmology training should be based on EBM. Regarding to familiarity with evidence based terminology, more than half of them have heard about them but less than 10% could explain these concepts to others (Fig 2). A dummy question was asked in this set of the questions to evaluate the value of the responses and surprisingly 67% knew about this term. About the implementation of information sources for problem solving, ophthalmologists preferred textbooks as a first priority (45%), Internet resources as a second priority (34%) and clinical guidelines as a third priority (26%). Meanwhile, 53 (53%) of respondents used the Internet for practice frequently, whereas this rate is 59 (59%) for using the Internet for finding ophthalmology clinical guidelines, and 31 (31%) of them used the Internet for finding clinical guidelines mostly. <br />The rate of utilization of databases and search engines for information retrieval differed among respondents (Table 1). Google and then Pubmed were the most popular online resources; whiles more than 60% of them have no familiarity with the Cochrane Library, MDconsult, TRIP and Embase. Unfamiliarity with Google Scholar was also remarkable (52%). <br /> <br />Sixty of respondents answered to the questions of the second questionnaire, whom 28 (46.7%) were faculty members and 32 (53.3%) were non-faculty. Table 2 shows the percentage of correct responses to each scenario among faculty members and non-faculty. Overall, non-faculties&rsquo; correct responses were more than faculties, but there was no significant difference between faculties and non-faculties correct answers to each question except to Questions 3 and 4.<br /> <br /> <br />To assess the percentage of correct response to various types of questions, a category of scenarios determined and correct answers to each category calculated (Table 3). In total, 36 (60%) and 37 (61.7%) of respondents answered both of questions correctly in &ldquo;Cataract-Evaluation&rdquo; and &ldquo;Glaucoma-Management&rdquo; category respectively. Forty four (73.3%) of them answered to more than 3 out of 5 questions in &ldquo;Cataract-Management&rdquo; category and 42 (70%) of them answered 2 out of 4 questions in &ldquo;Glaucoma-Management&rdquo; category.<br />In order to comparing ophthalmologists knowledge in cataract and glaucoma categories, mean scores of cataract and glaucoma per respondent calculated based on correct responses to each question. Then regarding to the number of questions in each category, the total mean score of cataract and glaucoma was determined (Cataract:67.61&plusmn;21.01; Glaucoma:55.55&plusmn;19.08). Comparing mean scores of cataract and glaucoma showed that mean score of cataract questions was more than glaucoma. However there was a significant correlation between glaucoma and cataract scores.<br /> <br />Discussion<br />In this study ophthalmologists&rsquo; attitude toward EBM was relatively acceptable. Although only one-tenth of ophthalmologists knew what EBM is but more than nine-tenth of them was aware of the benefits of EBM training and they were supporting the idea. Other studies in Iran had positive attitude toward the necessity of EBM training. In the other words, studies show the orientation of physicians about importance of learning and teaching of EBM for practice. It seems that implementing EBM in medical curriculum will be welcomed as concluded in the other studies.<br />Only less than 10% of ophthalmologists completely understood EBM terminologies which is notable. Other studies show a higher rate of EBM terminology awareness by physicians and surgeons, except Maaskant and colleagues results which show a less than 10% understood of NNT among participants. On the other hand, since respondents&rsquo; answer rate to the dummy term was nearly equivalent (66% somehow familiar) with other terms, it seems that answers to other question in EBM terminology can be vague. As understanding EBM related terms are indispensable for critical apprising and well-advised decision making, training these concepts seems necessary; and learning and teaching these terms will be easy with EBM training principles. Otherwise, as a second option, clinicians can use pre-appraised resources such as evidence summaries and practice guidelines for decision making which needs no more knowledge in critical appraisal. <br />Ophthalmologists had a little familiarity with evidence databases and Google Scholar, while using Google was 95%. Authors&rsquo; pervious study on university faculties and clinical residents had approximately similar results. Since Pubmed, MDconsult and TRIP have specific filters for guidelines, introducing and training these filters to practitioners in order to facilitate &lsquo;finding the best clinical practice guidelines&rsquo; is recommended. But although Cochrane library does not contain clinical guidelines, contains five databases including systematic reviews which are at the first level of evidence and are the best resources for developing clinical practice guidelines. Besides, studies on Google and comparing with other databases for finding best evidence show a competitive retrieval rate of Google and considering the high popularity of Google, training physicians how to use proper keywords in googling could lead them to comprehensive clinical guideline retrieval.<br />Surveyed ophthalmologists demonstrated a reasonable knowledge in both evaluation and management of cataract with overall 67.6% of correct answers, but less for glaucoma question with 55.5% and a weak correlation between glaucoma and cataract scores. Our previous study shows training of the cataract management in Iranian ophthalmology curriculum is more highlighted which can echo this difference.<br />Overall, respondents&rsquo; reasonable rate of correct answers to cataract and glaucoma questions shows that they are aware of new developments and updates in this field. Regarding highly use of Internet for finding ophthalmology clinical guidelines by surveyed ophthalmologists (59%), building and enhancing national user-friendly CPG databases will have a positive impact on their potential knowledge and practice. Other studies also reported such a positive attitude toward clinical guidelines. However the rate of guideline implementation in practice is not acceptable and granted yet and according to Ishii there is a clinical gap between knowledge and practice. As CPGs are in the highest level of evidence pyramid, training of evidence based practice and implementing CPGs in the ophthalmology curriculums is crucial. This need was pointed in Baradaran-Seyed and colleagues study as one of the main barriers for implementation of the guidelines in Iran.<br /> <br />Conclusion:<br />Current study showed an acceptable knowledge and attitude toward evidence based practice of Iranian ophthalmologists. This finding is expressed in their self-reported evidence based daily practice. Teaching how to implement of the clinical guidelines in ophthalmology curriculum will eliminate some of the barriers of evidence based practice. <br /> <br />~ 8 ~