Our previous paper identified, from a search of the available research and information, the key issues in moving towards evidence-based general practice in rural and remote Australia1. There has been little research to understand the use of EBM by general practitioners (GPs) practicing in these areas and whether or not the identified barriers to the practice of evidence-based medicine (EBM)2-5 are more pronounced in rural/remote general practice. There may be fewer differences now in Australia in clinical general practice activity in rural/remote areas compared with urban areas6. However the rural and remote context of practice may be associated with difficulties in accessing and applying evidence.
There is an imperative to move towards EBM in rural and remote areas because patients often have a limited choice of health-care options. Designing appropriate strategies to encourage the widespread application of EBM in rural and remote Australia could assist in ensuring those options provide effective health care. This study provides information that may be useful in designing such strategies.
The survey was undertaken among 89 of 104 GPs (86%) practicing in three rural Divisions of General Practice in the year 2000. Ethics approval was obtained from the Human Research Ethics Committee of the University of South Australia, Australia. Trained interviewers administered a 28-item survey at the GP's surgery. Demographic and other information such as location and membership of associations was obtained. GPs were asked open-ended questions about their views on EBM, whether they thought they practiced it, the barriers they experienced in practicing it and if they found barriers, possible solutions to overcome these barriers. The Divisions of General Practice invited participation and GPs were paid AU$50 for their time.
Definition of EBM: Interviewers outlined the following definition prior to conducting the interview and used it in the interview:
- The use of information in clinical decision-making obtained from research, including systematic reviews and meta analysis of randomised controlled trials, or information from evidence-based clinical practice guidelines7.
Participants and setting: Using the Accessibility/Remoteness Index of Australia (ARIA)8, 30% of GPs who participated were located in a remote or very remote area. Seventy-one per cent of participants worked in group practices or collaborations with 29% working in solo practice. Almost three-quarters of participants were male (72%). Forty per cent of participants were in the age group 45-54 years; with 11% being younger than 35 years and 21% older than 54 years.
Two researchers individually analysed the first 10 interviews and developed categories from these responses. The remaining interviews were then analysed, further categories identified, and responses were placed in these categories by one researcher. As a reliability check, a different researcher checked random surveys and noted whether or not they agreed with the categorisation. Where there was disagreement discussion occurred and consensus reached about where to categorise these data. Like categories of data were amalgamated into themes and the number of respondents presenting a theme were tallied. SPSS 8.0 (SPPS Inc, Chicago, IL, USA) for Windows was used to analyse quantitative data.
Views of EBM
GPs overall (85%) viewed EBM positively and most (94%) considered that they practiced EBM. Of those who viewed EBM positively, 22% thought EBM was good in theory but there was a gap between theory and practice and 20% thought they had always practised this way and did not regard EBM as a new development.
Barriers to practising EBM
In all, 84% of GPs reported perceived barriers to the practice of EBM. These barriers were categorised as: GP related barriers; patient related barriers; environmental barriers; and resource barriers. The proportions presented here are in relation to the group of GPs who perceived barriers.
- GP related barriers: Sixty per cent of GPs were uncertain where to look for evidence, how to find it quickly, how to deal with conflicting evidence and how to determine the level of the evidence. Some GPs (17%) considered that individual practitioner change was required in order to practice EBM and that they had 'done certain things in a way that work for the GP and the patient for years without an awareness that there isn't an evidence base for it'. The 'new' practice may be substantially different from that used before and require commitment and effort.
- Patient related barriers: In all, 23% of GPs considered that patients' expectations acted as a barrier to practicing EBM. At times some GPs reported it hard to convince patients that they did not need a (non-evidence-based) treatment and often experienced pressure to meet patient demands.
- Environmental barriers: The rural/remote location of practice was considered a barrier by 43% GPs. GPs identified isolation from colleagues; difficulty in attending continuing medical education events; adjustments to practice because certain treatments or tests were not available to country residents; the workload in rural general practice; and lack of evidence resources at hand when working from different locations.
- Resource related barriers: Limited time to spend reflecting on practice and accessing evidence was identified as a resource issue by 29% of GPs. Some GPs (16%) identified gaps in evidence relevant to general practice and a lack of resources to encourage GP research. The speed of Internet access in rural areas, cost factors in using the Internet (inability to dial the Internet service provider for the cost of a local call), a lack of computer hardware and appropriate software affected 14% GPs.
GPs' solutions to overcome barriers to practicing EBM
The solutions presented by GPs were diverse and reflected the complex interaction of factors that acted as perceived barriers to the practice of EBM. In all 82% GPs identified solutions and the proportions presented here are in relation to this group of GPs. Solutions were categorised as: GP related solutions; patient related solutions; resource related solutions; and solutions that require structural changes in the way general practice is organised in rural and remote areas.
- GP-related solutions: In all, 19% of GPs suggested that continuing medical education events using various styles of presentation, self-learning, seminars, academic detailing and a travelling 'road show' would provide new information about EBM. In addition 14% Gps required easier access to and training to use the Cochrane Library. Giving sound reasons to change clinical practice and 'demystifying' EBM were solutions suggested by 14% GPs to overcome resistance to a new way of practicing.
- Patient related solutions: Patient education about the evidence base of treatments, particularly antibiotics, was seen as necessary by 10% GPs. Handouts for patients and television campaigns were among the methods suggested to achieve patient education.
- Resource related solutions: According to 41% GPs, improvements in computer hardware and software and quicker and cheaper Internet access would make the Internet more accessible, and hence might increase the practice of EBM. Improvements in clinical practice guidelines (CPG), for example, to collate CPG in summary form; provide a list of
best evidence-based guidelines and put CPG on one disease entity together were solutions identified by 26% GPs. A further 23% GPs suggested non-Internet based resources to disseminate evidence including a service to find evidence to quickly answer a clinical question. Finally 14% GPs recommended increasing the amount of research in general practice.
- Structural changes in general practice: Only a small number of GPs suggested structural changes in rural general practice. These were, to increase the permanent rural workforce to enable GPs to have more time (8%) and to provide financial incentives to practice EBM (5%).
Our survey indicates that rural and remote GPs are supportive of the move to EBM but they noted that there are key barriers to practising this way. Over half of those who perceived barriers acknowledged difficulty in knowing where to look for evidence, identifying the level of validity of evidence and dealing with conflicting evidence, the 'heart' of EBM9. This is consistent with previous research that found barriers to practising EBM are perceived by GPs as gaps in knowledge, experience and skills, time pressures and patient requests conflicting with effective health care3,5. In addition, GPs in the present study identified the rural location as an additional factor to be overcome. Importantly, our data acknowledges the effect of isolation, workload, and the lack of resources that are perceived as barriers to the uptake of EBM in rural and remote general practice.
This study also provides some insights into how GPs practising in rural and remote areas consider the barriers to practising EBM may be overcome. Suggestions covered all four areas relevant in changing clinical practice, organisational change including increasing resources, access to new information, training and behavioural change10. However suggestions were more frequently related to resource issues rather than the need to change clinical practice. While over half the GPs said they found it difficult to find, appraise and apply evidence, less than one-quarter suggested that they needed training to address this issue. There were even fewer suggestions relating to changing the organisation of general practice.
Research/strategies to increase the uptake of EBM
Much has, and is being done, to increase the uptake of EBM. The National Institute of Clinical Studies (NICS) 11 is doing important work to bridge the gap between evidence and practice. Broad strategies suggested by NICS to encourage change include increased use of technology to access evidence and education leading to behavioural change. Resources are now available to access evidence at the point of care. For example clinical evidence is available now in hard copy, Web based, CD ROM and Palm hand-held devices12. In Australia, University Departments of Rural Health and Rural Clinical Schools are providing a rural academic network that complements the work of Divisions of General Practice13. The National Health and Medical Research Council (NHMRC) has resourced research strategies to increase EBM14 and work is being done by the Royal Australian College of General Practitioners to develop comprehensive and accessible clinical practice guidelines15.
Undoubtedly there are gaps in the evidence base to support clinical practice in rural and remote areas, however in the absence of relevant randomised controlled trials there is a body of 'best evidence' available through the BMJ Publishing Group's Clinical Evidence12. Furthermore, developing resources for patients about evidence-based treatments, for example, the leaflets produced by the South Australian campaign to reduce antibiotic consumption16, may assist GPs implement EBM with their patients. Internet sites, such as the Cochrane Consumer Network17, may enable better access for patients to research information.
If GPs are to change their clinical practice to move towards EBM, they need to be engaged in a multifaceted change process. Expressing positive attitudes towards EBM may in itself not result in change, but it is an important start. Changing clinical practice is complex and requires organisational supports, acquisition of new knowledge and application of skills learnt. Any one strategy in isolation is unlikely to be successful.
There seem to be factors that are particular to GPs practising in rural and remote areas that may make the process of change more difficult. These GPs are relatively isolated from a culture to develop and support EBM. They may have difficulty in accessing practical workshops and may have problems with the speed and cost of the Internet. They may be remote from academic detailing that might assist in changing clinical practice. Therefore in designing strategies to be used in rural and remote areas, the barriers and solutions identified by GPs working in these areas should be considered.
The research was funded by a grant in 2000 from the Rural Health Support Education and Training (RHSET) Program of the Commonwealth Department of Health and Aged Care, and was conducted in collaboration with the Eyre Peninsula, Flinders and Far North and the Mid North Divisions of General Practice. The cooperation of the general practitioners in these Divisions is acknowledged.
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Published 27 August 2002; styling modified 19 May 2003.