Improving evidence-based general practice

Abstract

This thesis provides knowledge on how to improve the practice of evidence-based medicine (EBM) by general practitioners (GPs) and GP trainees. EBM is defined as the integration of clinical expertise, patient values and the best available clinical evidence in daily clinical practice. We describe the current clinical evidence base in general practice (GP), both nationally and internationally. The number of RCTs in the general practice domain published worldwide has tripled in the past 20 years. The number of RCTs from the Netherlands has even increased fivefold. However, the themes of this research correspond insufficiently with the clinical problems presented in daily practice.The nationwide database of on-going general practice research projects in The Netherlands we constructed shows that there is a substantial body of on-going research in general practice in the Netherlands, covering a wide range of topics. The majority of this research has a clinical perspective, a high quality research design (RCT), and is non-commercially funded. The topics of these projects do not adequately match with the major reasons for encounter in the Dutch general practice as well; especially clinical questions in dermatology, ophthalmology, reproductive medicine, and gastro-enterology are insufficiently addressed. Moreover, we describe the information needs and seeking behaviour of trainees. GP trainees frequently encounter clinical queries in daily clinical practice, perform searches in the vast majority, and retrieve answers in most cases. They use colleagues as their primary source of information. In the Netherlands, their second most frequently used source of information is the national professional GP guideline database. Other evidence-based Internet resources such as primary or pre-appraised research are used very infrequently. Trainees mostly perform searches during patient consultations. Most queries regard therapeutic questions. The trainees consider most of the answers they find as relevant, i.e. they do change patient’s management. Finally, we compared the effects of two EBM training programmes for GP trainees on outcomes relevant to daily clinical practice; stand-alone versus integrated EBM training. In the stand-alone EBM training programme EBM is trained in theoretical, stand-alone educational sessions. This differs from integrated EBM training, in which EBM is trained in a clinical context (as well), and teaching sessions are based on recent patient consultations in the trainees practice. We measured the effects with feasible, reliable and valid instruments, of which two were developed and validated by us, the Utrecht questionnaire on knowledge on Clinical epidemiology for Evidence-based Practice (U-CEP) and an instrument that assesses adherence to professional guidelines. The latter facilitates assessment of three relevant aspects of clinical management decisions (diagnosis, therapy, and referral) for a wide variety of disorders. The integrated EBM training programme did not improve EBM performance as compared to stand-alone EBM training. Overall, adherence to guidelines among GP trainees is high in all phases of their training, ranging from 69 to 95%, depending on the type of management decision. In more than 50% of the consultations trainees adhere to the guideline for all major management decisions.