Family Practice Vol. 18, No. 4, 364-366
© Oxford University Press 2001
Promoting evidence-based medicine in general practice—the impact of academic detailing
Monash Division of General Practice and
a Monash University Department of General Practice, East Bentleigh, Victoria, Australia.
Associate Professor Peter Schattner, Monash University Department of General Practice, 867 Centre Rd, East Bentleigh, Victoria, Australia 3165.
Markey P and Schattner P. Promoting evidence-based medicine in general practice—the impact of academic detailing. Family Practice 2001; 18: 364–366.
Received 12 October 2000; Revised 2 March 2001; Accepted 12 March 2001.
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Abstract |
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Background. We undertook a project to promote evidence-based medicine (EBM) within a network of GPs (the Monash Division of General Practice) in Melbourne, Australia. A principal promotional strategy was to conduct practice visits (‘academic detailing’).
Objectives. The aim of this study was to measure the impact of academic detailing on GP attitudes and knowledge of EBM.
Methods. All 132 GP members of the division were invited by mail to accept a practice visit about EBM. The GPs had been randomized to one of two groups: to receive academic detailing during the study period or to be visited at a later date. The practice visit consisted of a 30– 45 minute discussion about EBM and the barriers to its practice. Pre- and post-intervention questionnaires were used to measure change in knowledge of and attitudes to EBM over a 3-month period in both groups.
Results and Conclusions. Academic detailing led to a significant improvement in knowledge scores and self-perceived understanding of EBM, but had little influence on GP attitudes toward it. It is not known whether this would lead to change in clinical behaviour among GPs.
Keywords. Academic detailing, evidence-based medicine, family practice, randomized controlled trials.
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Introduction |
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The Monash Division of General Practice is a network of GPs in the south-eastern suburbs of Melbourne, Australia, and is one of 123 divisions of general practice established and funded by the Australian Commonwealth Government in the 1990s. At the Monash Division, we developed a project which aimed to promote evidence-based medicine (EBM) to GPs. To achieve this aim, we chose academic detailing as a strategy because it has been shown to be effective in changing GP behaviour in other circumstances.1 We measured the impact of our strategy by using a randomized controlled trial design.
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Methods |
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The target sample for the study was all members of the division (n = 132). The members were randomized into control and intervention groups using the random number generator in the Microsoft Excel 97 program. Both groups were mailed the questionnaire with an accompanying letter which made reference to the academic detailing, stating that this would be offered either immediately (for the intervention group) or in 3 months (controls). ‘Non-responders’ were followed up with a further questionnaire and phone call using a standard survey protocol. A ‘post-intervention’ questionnaire was mailed out 3 months later to both groups, with the control group then being offered a practice visit. GPs were paid A$50 for their time in undertaking the academic detailing.
A questionnaire which assessed GPs' knowledge of and attitudes to EBM was devised by the authors, based largely on one piloted and then used in general practice in the UK.2 This consisted of 10 questions on attitudes to EBM using a five-point Likert scale (items included enquiries into the usefulness of EBM and barriers to its practice) and six multiple choice questions to measure knowledge (see Table 1
for examples). Demographic data were also collected. A total attitude score was derived from the sum of the attitude questions (converted to give a score out of 100), and a knowledge score was given by converting the number correct to a percentage.
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The academic detailing commenced with an introduction to EBM and went on to explore the GPs' attitudes to and knowledge of EBM. GPs who completed pre- and post-intervention questionnaires were included in the analysis. The change in scores between the pre- and post-questionnaires was calculated for each GP, and comparisons between the change in scores in each group were made using parametric methods (t-test) for the knowledge scores and non-parametric methods (Mann– Whitney U and Wilcoxon signed rank tests) for the attitude scores. Before and after change for dichotomous variables was analysed using Fisher's exact test or McNemar's chi-square test. The results were analysed using EpiInfo 6.04, Stata and Statview. A probability level of P < 0.05 was considered statistically significant.
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Results |
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Sixty-four GPs completed both questionnaires, which represents a response rate of 48% [intervention group 34 (52%), control group 30 (45%)]. Among participants who returned both the pre- and post- questionnaires, there were no statistically significant differences between the two groups for sex, age group, position in the practice, full-time/part-time status, or knowledge, attitude or practice of EBM (see Table 1
). Non-parametric analysis of the Likert scores failed to reveal any significant difference between the groups for any of the attitude questions at baseline. Multivariate regression analysis of the pooled baseline data revealed an inverse association between baseline knowledge scores and age (P < 0.01) after controlling for sex, number of principles in practice, full-time/part-time status, group (intervention or control) and attitude score.
At follow-up, knowledge scores in the intervention group had improved significantly compared with those of the control group [difference in change of scores: 11.8% (95% confidence interval 0.8–22.9% for improvement in scores), P = 0.036]. These are summarized in Table 1.
Overall attitude scores increased significantly in both groups during the 3-month trial period (intervention group, P < 0.01; controls, P < 0.01, Wilcoxon signed rank test) with no statistically significant difference between the groups (P = 0.88, Mann–Whitney U test). Analysis of the individual scores for each question revealed that for only in one question, ‘I believe I understand the principles of evidence-based medicine’, did the intervention group show a statistically significant improvement compared with the control group (P = 0.027 for difference in improvement of scores, Mann–Whitney U test). Multivariate regression analysis revealed that improvement in attitude scores was not influenced by sex, age, number of principals in practice, full-time status or baseline knowledge scores.
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Discussion |
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The response rate of 48% of GPs in the division may be due to the controversial nature of EBM,3,4 excessive demands and ‘overload’5 or the well-known constraints on GPs' time. It is possible that the group which agreed to academic detailing were more favourably disposed toward EBM. However, this would mean that the positive findings in this study only refer to GPs who are willing to be academically detailed, which is not necessarily a shortcoming for GP professional organizations contemplating such an intervention.
There was an overall improvement in GPs' attitudes towards EBM throughout the study period, irrespective of whether they underwent academic detailing. This may have been due to other promotional activities being conducted by the division and other sources throughout the period, but may also have been due to the GPs' awareness of the project stimulating an enthusiasm for EBM. In addition, it is likely that GPs who volunteered for the study were those already developing an interest in EBM and this simply continued throughout the study period. Contamination between groups by GPs in the same practice was also a possibility, but was thought to be unlikely.
The lack of influence which academic detailing had on GPs' attitudes to EBM was not surprising given the short time allowed for the practice visits and the complexity of many of the issues associated with EBM. EBM is to a large extent a framework for clinical practice; it challenges clinicians to examine their own knowledge base in a fundamental way, and therefore attitudes to it are unlikely to change easily.
Our survey instrument was based on one used in the UK in a postal survey whose aims were to measure GPs' attitudes to and knowledge of EBM. However, we do not claim that the knowledge and attitude measures are valid indicators for either ‘knowledge of EBM’ or ‘attitude to EBM’ concepts. The overall knowledge and attitude scores are simply summary statistics for a set of questions about these domains. Although not all the data are presented here, the pattern of significant improvement in knowledge following academic detailing is consistent for five out of the six questions.
The study suggests that, for divisions and other medical organizations contemplating a project to increase awareness and practice of EBM, it is reasonable to consider academic detailing as a strategy, provided there is an awareness of the costs involved. A cost–benefit analysis was not within the scope of this study but it is recognized that the strategy is expensive, the principal cost being the salary of a qualified EBM ‘detailer’.
In summary, the results of this study suggest that academic detailing may have an impact on GPs' knowledge and self-perceived understanding of EBM but little influence on their attitude to it.
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Acknowledgments |
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This paper is a product of the ‘Promoting and Supporting Evidence Based Medicine through Divisions of General Practice’ project which was funded by the Australian Divisions of General Practice through the Australian Commonwealth Department of Health and Aged Care. We would like to thank Dr Rod Trevena for his enthusiastic support, together with Professor Chris Silagy, Associate Professor Jeremy Anderson and Mr Frank Fisher from the reference group, and Dr Con Tsalamandris for his statistical analysis. We also acknowledge the support of staff at the Monash Division of General Practice, and the Department of General Practice at Monash University. Finally, we wish to acknowledge the support and enthusiasm of the GPs of the Monash Division.
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References |
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1 Thomson O'Brien T, Oxman AD, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes (Cochrane Review). The Cochrane Library. Issue 4. Oxford: Update Software, 2000.
2
McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. Br Med J 1998; 316: 361–365.
3 Wilkinson EK, Bosanquet A, Salisbury C, Hasler J, Bosanquet N. Barriers and facilitators to the implementation of evidence-based medicine in general practice: a qualitative study. Eur J Gen Pract 1999; 5: 66–70.
4
Mayer J, Piterman L. The attitudes of Australian GPs to evidence-based medicine: a focus group study. Fam Pract 1999; 16: 627–632.
5 Salisbury C, Bosanquet N, Wilkinson E, Bosanquet A, Hasler J. The implementation of evidence-based medicine in general practice prescribing. Br J Gen Pract 1998; 48: 1849–1851.[Web of Science][Medline]
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