Teaching and learning evidence-based medicine: cross-sectional survey investigating knowledge and attitudes of teachers and learners in primary and secondary care

Evidence-based medicine (EBM) is an important component of quality healthcare and a key part of the curriculum for doctors in training. There have been no previous studies comparing attitudes and knowledge of doctors in primary and secondary care towards EBM practice and teaching and this study sets out to investigate this area. We asked participants, a stratified sample of general practitioners, hospital consultants, GP registrars and junior hospital doctors in Leicester, Northamptonshire and Rutland, UK, to complete a self-administered survey questionnaire and written knowledge test which provided ‘positive to evidence based practice’ (PEP) attitude scores and Manchester Short EBM Questionnaire Education for Primary Care (2007) 18: 45–57 # 2007 Radcliffe Publishing Limited WHAT IS ALREADY KNOWN IN THIS AREA. There is little evidence on the relationship between attitudes and knowledge in relation to evidence-based medicine (EBM) in family doctors, consultants and doctors intraining. WHAT THIS WORK ADDS. This study showed that, although general practitioners and general practitioner trainers were significantly less positive in attitude to EBM compared to GP registrars, junior hospital doctors and consultant respondents, they had significantly higher knowledge scores. This study demonstrated that the attitude (PEP) score and knowledge questionnaire(MANSEBMQ) have high reliability but require further research to demonstrate validity. SUGGESTIONS FOR FURTHER RESEARCH. There remain opportunities for refinement of the MANSEBMQ, validation against existing tools and further application in a larger study, including assessment of EBM knowledge and skills, before and after an educational process, involving students in clinically relevant and integrated EBM learning. Keywords: attitudes, evidence-based practice, general practice registrars, general practitioners, hospital doctors, primary care, secondary care(MANSEBMQ) knowledge scores of participants. The response rate was low which may have led to volunteer bias but there were sufficient responses to explore attitude scores and knowledge scores. Attitude(PEP) scores were highest in hospital consultants, intermediate in doctors in training and lowest in general practitioner (GP)respondents (mean score 71.7 vs 70.5 vs 67.2; P = 0.006). PEP scores were also highest in respondents with higher degrees (MD, PhD, MSc), intermediate in those with higher professional qualifications (MRCP, FRCS, MRCGP or equivalent) and lowest in those with none of these (mean score 72.9 vs 70.6 vs 67.2; P = 0.005). PEP scores were significantly higher(P = 0.002) in respondents who taught EBM (mean score 71.7, 95% CI 70.3 to 73.2, n=109, missing=5) compared with those who did not (mean score 68.6, 95% CI 67.3 to 69.9, n = 105, missing = 12) and in respondents with research experience (P < 0.001), research training (P < 0.001) and training in EBM (P = 0.001). There was a positive correlation between PEP score and MANSEBMQ score (P = 0.013). In contrast, and paradoxically opposite to the pattern of attitudes, knowledge scores were highest in GPs, intermediate in junior hospital doctors and lowest in consultant respondents (mean score 63.5 vs 61.9 vs 54.5, P=0.005). Although GPs and GP trainers were significantly less positive in attitude to EBM compared to GP registrars, junior hospital doctors and consultant respondents, they had significantly higher knowledge scores. This study demonstrated that the attitude(PEP) score and knowledge questionnaire (MANSEBMQ) have good reliability but require further research to demonstrate validity

Climate Related Mortality and Morbidity in Scotland: Modelling Time Series of Counts

Earlier research has demonstrated that excess winter mortality is greater in the countries of the United Kingdom than in those on comparable latitudes elsewhere in Europe. The purpose of this thesis was to provide an up-to-date analysis of excess winter mortality in Scotland. This involved exploring the relationships between mortality, morbidity (as reflected in rates of emergency hospital admissions), climate, influenza epidemics, and socio-demographic variables. The majority of the analysis was concerned with temporal relationships between these variables, however, latterly spatial relationships were also considered. Chapter 1 reviews the literature in support of seasonal patterns in health and assesses the merits of the various statistical techniques that have been used to demonstrate these patterns. Much of the previous analyses have used simple descriptive statistical methods with few acknowledging the Poisson time series nature of the data. In chapter 2 the seasonal pattern of mortality and morbidity from three main disease groups was described using a generalised linear model with Poisson errors incorporating a cosine term. The method was used to analyse the seasonal pattern by sex, age group, social class, deprivation category and health board. In chapter 3 the effect of climate on mortality and morbidity is explored. This chapter is chiefly concerned with the comparison of possible methods of analysis. Firstly the problems with summary methods are demonstrated before the principles of time series methodology are introduced. The final comparison involves three methods, ARIMA time series methods, Poisson regression and Zeger's method. Zeger's method is as a time series regression method for Poisson data. The methods are compared by assessing the effect of temperature on weekly deaths from respiratory disease. Examination of the residuals and the standard errors of the model coefficients reveal that Zeger's method is the most appropriate for this type of analysis. Zeger's method is used in Chapter 4 to assess the relationship between temperature and mortality and morbidity in more detail, by considering the effects of age, socio-economic deprivation and city of residence. This chapter also includes a detailed examination of the effects on mortality of a variety of different temperature patterns. In chapter 5 the spatial aspect of the data is included in the analysis. Space-time variations in emergency admissions for respiratory disease are assessed at various levels of aggregation. Overall there is no clear evidence of space-time patterns in emergency respiratory admissions over the time period, however spatial relationships are demonstrated. Finally, methods which account for spatial autocorrelation are used in an analysis of the relationship between emergency admissions and socio-economic deprivation in Glasgow. This analysis demonstrates, as with the previous temporal analysis, that if autocorrelation exists it is vital to account for this in any modelling procedure. Chapter 6 provides a summary of the main findings of the analysis in terms of both the epidemiological results and the methodological concerns. The limitations of the study concerning problems associated with the use of routinely collected data are also recognised. The thesis has demonstrated that seasonal patterns in mortality and morbidity are still a significant public health problem in Scotland and that Zeger's method is the most appropriate method to use when assessing the direct relationship between climate and ill health

Helping to prioritise interventions for depression and schizophrenia: use of Population Impact Measures

BACKGROUND: To demonstrate the potential of Population Impact Measures in helping to prioritise alternative interventions for psychiatry, this paper estimates the number of relapses and hospital readmissions prevented for depression and schizophrenia by adopting best practice recommendations. The results are designed to relate to particular local populations. METHODS: Literature-based estimates of disease prevalence, relapse and re-admission rates, current and best practice treatment rates, levels of adherence with interventions and relative risk reduction associated with different interventions were obtained and calculations made of the Number of Events Prevented in your Population (NEPP). RESULTS: In a notional population of 100,000 adults, going from current to 'best' practice for different interventions, the number of relapses prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 23 (family intervention), 43 (relapse prevention), and 44 (early intervention); and for depression the number of relapses prevented in the next year were 100 (increasing care management), 227 (continuing treatment with antidepressants), 279 (increasing rate of diagnosis), and 325 (Cognitive Behaviour Therapy). Hospital re-admissions prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 36 (relapse prevention) and 40 (early intervention). CONCLUSION: Population Impact measures provide the possibility for a policy-maker to see the impact of a new intervention on the population as a whole, and to compare alternative interventions to best improve psychiatric disease outcomes. The methods are much simpler than others, and have the advantage of being transparent

Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?

AbstractObjectivesThis study examined the relative merits of digoxin, carvedilol, and their combination for the management of patients with atrial fibrillation (AF) and heart failure (HF).BackgroundIn patients with AF and HF, both digoxin and beta-blockers reduce the ventricular rate, and both may improve symptoms, but only beta-blockers have been shown to improve prognosis. If combined therapy is not superior to beta-blockers alone, treatment of patients with HF and AF could be simplified by stopping digoxin.MethodsWe enrolled 47 patients (29 males; mean age 68 years) with persistent AF and HF (mean left ventricular ejection fraction [LVEF] 24%) in a randomized, double-blinded, placebo-controlled study. In the first phase of the study, digoxin was compared with the combination of digoxin and carvedilol (four months). In the second phase, digoxin was withdrawn in a double-blinded manner in the carvedilol-treated arm, thus allowing a comparison between digoxin and carvedilol (six months). Investigations were undertaken at baseline and at the end of each phase.ResultsCompared with digoxin alone, combination therapy lowered the ventricular rate on 24-h ambulatory electrocardiographic monitoring (p < 0.0001) and during submaximal exercise (p < 0.05), whereas LVEF (p < 0.05) and symptom score (p < 0.05) improved. In phase 2, there was no significant difference between digoxin alone and carvedilol alone in any variable. The mean ventricular rate rose and LVEF fell when patients switched from combination therapy to carvedilol alone. Six-minute walk distance was not significantly influenced by any therapy.ConclusionsThe combination of carvedilol and digoxin appears generally superior to either carvedilol or digoxin alone in the management of AF in patients with HF

Prioritising between direct observation of therapy and case-finding interventions for tuberculosis: use of population impact measures

BACKGROUND: Population impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritising potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding. METHODS: PIMs were calculated using published literature and national data for India, and applied to a notional population of 100 000 people. Data included the incidence or prevalence of smear-positive TB and the relative risk reduction from increasing case finding and the use of direct observation of therapy (applied to the baseline risks over the next year), and the incremental proportion of the population eligible for the proposed interventions. RESULTS: In a population of 100 000 people in India, the directly observed component of the Directly Observed Treatment, Short-course (DOTS) programme may prevent 0.188 deaths from TB in the next year compared with 1.79 deaths by increasing TB case finding. The costs of direct observation are (in international dollars) I$5960 and of case finding are I$4839 or I$31702 and I$2703 per life saved respectively. CONCLUSION: Increasing case-finding for TB will save nearly 10 times more lives than will the use of the directly observed component of DOTS in India, at a smaller cost per life saved. The demonstration of the population impact, using simple and explicit numbers, may be of value to policy-makers as they prioritise interventions for their populations