Barriers to Evidence Informed Practice in South Asia and possible solutions

SYNOPSIS
· Introduction
· EBM – the buzzword of the day
o A boon to the stressed Indian doctor
o The problem of experts
o Lack of research awareness
o Lack of uniformity in health services
o The “cuts” practice
o Paucity of specialist care in periphery
o The drug company game
o Paucity of quality research
· Possible solutions
o Initiating EBM awareness in Medical colleges
o Framing Evidence based guidelines
o Collaboration with local bodies
o Increasing resources
o Effective training
o Checking drug companies
o Involving governments
· Epilogue

Barriers to Evidence Informed Practice in South Asia and possible solutions
Abstract:

Having been widely accepted and practiced in the West, implementation of evidence informed practice in the south Asian region has unique challenges to be faced. Resource poor settings, lack of research awareness, paucity of high quality research, absence of regulations for continuing medical education for practitioners, diverse range of health care providers, scarcity of professional bodies with a strong research background which can frame evidence based guidelines are some of the many barriers in the way. The attitude of doctors towards EBM, the acceptance of change, the ways and means of training faculty who can train others, computer literacy are issues which require intense study for assessing feasibility. State participation, involvement of local bodies, development of ingenious training methods, increasing accessibility, regulating private practice, guidelines regarding continuing medical education, encouraging research among practitioners are actions to be planned and executed. Convincing health planners that EBM can cut down unnecessary costs by providing the right treatment for the right patient is needed to get essential managerial support. Efficient curriculum planning for inciting a zeal for research and research based practice among medical students would produce doctor- scientists. The drug industry has to realize its duties. An inherent outcome assessment method should also be thought of to measure the results of evidence based practice. Creating public awareness, improving literacy can make the patient an active member of the team taking treatment decision for him/her. The need for practice based on evidence has to be understood by the leaders, junior doctors, planners, purchasers and the public. The ways and means can then be worked out and implemented so that the best of the treatment goes to the suffering patient.


Introduction:
“. . . To fix a health care system distorted by spiraling costs . . . true reform needs to go farther. Certainly any far reaching reform must make greater use of evidence-based medicine . ..”
— “Healing Health Care” The Washington Post, May 15, 2004

Man, through ages has always strived to extract the best out of anything he comes across. In these times of ever shrinking resources, it is more important than ever that we deliver the most time and cost-effective treatment available to the patient. Evidence based medicine (EBM) is such an attempt to make the best possible use of the whole wealth of research experience available for the day to day care of the lay patient. The concept as such is wonderful and is being widely embraced all over the developed world by clinicians, public health practitioners, purchasers, planners, and the public. Nevertheless, there has been resistance. One scientist estimated that 19% of medical practice was based on science and the rest on “soft-science” or opinions, clinical experience, or “tradition.” Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom1. But the scenario in a developing country is entirely different. There are a lot of obstacles, for the fruits of EBM to reach the common mass, many of which are not encountered in the west. This essay is an attempt to discuss some of the important barriers in the practice of evidence informed practice in south Asian countries and some possible solutions to address these.

EBM –the buzzword of the day:
Sackett defined Evidence Based Medicine as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. External information is blended with clinical expertise in order to decide if and how this evidence may relate to the individual patient. The aim is to inform practice and see if the treatments that are used are the most powerful, accurate, effective and safest options1. The interest it has created in the medical fraternity is evident from the number of workshops and training courses being organized in perpetuating this concept. Many journals have started a section for EB M3,4. The role played by the Cochrane collaboration in making EBM the buzzword of the day cannot be over emphasized. Guidance at each and every step of performing a review, appropriate help at the appropriate time, comradeship and brotherly gentleness are some of the characteristics of the Cochrane collaboration which are very rare to find in the field of research in general and medical research in particular. The painstaking attempt to spread the awareness about EBM by the Cochrane and similar groups have slowly started bearing fruit in the western world but still a lot of work has to be done in the third world.
A boon to the stressed Asian doctor
In the South Asian context, what is the relevance of EBM? EBM has got the greatest relevance in countries like India. Some of the salient features of Indian medical education and practice are:
· Old fashioned teaching and stiff resistance to modern teaching methods in many peripheral teaching hospitals
· Stiff competition for the meager post graduate seats in countries like India and the mindset among medicos to get “settled” only with a PG seat resulting in many futile years of pre PG preparation
· Much disorganized practice methods with mixed private public healthcare setups and the now booming corporate hospitals
· Lack of enthusiasm among general practitioners for continuing medical education programs
· Scarcity of strong professional bodies with good research background to formulate local guidelines
· Lack of interest and encouragement in clinical and basic research
· Specialty practice still being in infancy in many parts of the country
· The under informed and uneducated patient
· Lack of co ordination between health planners and health care providers
· A disproportionately low allocation of funds for health care by the state
· Lack of medical insurance
In this confusing scenario, Evidence Based Medicine has come as a boon to the Indian medical practitioner. Keeping abreast with newer treatment modalities and maintaining a track of all the happenings in the field of research is almost impossible for a general practitioner in the periphery who not only has very less time for educating himself but also has no access to research data. If EBM can reach him/her, the quality of care is bound to improve and the real benefits of all the hard work put into research can be achieved.
The problem of experts:
Whenever in doubt, we get an expert opinion. The experts are in fact deciding authorities, at least in this part of the world where treatment options are rarely discussed with the patient for the patient to make an informed choice of what treatment he should get. The resistance in part of these experts to accept evidence based practice is well known in the west too. Clinical expertise means the proficiency that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care1. Good doctors use both individual clinical expertise and the best available research evidence, and neither alone is enough. They must be able to substantiate the decisions they have made on a foundation of professional expertise which clearly includes using relevant evidence to inform practice. Evidence informed practice does not suggest practicing "cookbook" medicine. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. Evidence and expertise must go hand in hand and experts must realize this fact for providing the best treatment for the patient.

Lack of research awareness:
Lack of research awareness is a major barrier in the implementation of evidence informed practice. There is little organized high quality research being done and published in majority of the hospitals and institutes despite the abundance of clinical material in this part of the globe. There is little awareness about the results of various studies done in the west to the general practitioner. Inability to access internet and medical information in the net and lack of training in searching and retrieving necessary material is the major factor impeding the implementation of research based practice. Lack of confidence in evidence based medicine and basing treatment practices upon tradition has to be tackled. Statistics are commonly viewed as a complex method of supporting incorrect information by ‘massaging’ data and manipulating results to support anything an author decides is significant. In other words, statistics are the tool of the devil that gives the answer intended by the author, which may vary from ‘the truth’2 If evidence-based practice is to become a reality, individuals require a positive regard, the knowledge, understanding, competence, and skills to critically review research and assess its relevance to practice 3
Experts opine that three prime factors are necessary for the practice of evidence based medicine 4, 5, 6
Attitude
Understanding and confidence
Support
The attitude of medical men towards research has been studied by several authors. Several investigators report that lack of knowledge and understanding of the research process are main reasons for the general practitioner’s lack of involvement in research. McSherry, Estabrooks and Glacken highlight several barriers associated with integrating evidence into practice, including:
Lack of time to access and review the evidence.
Lack of skills to read, critique, and understand the evidence.
Lack of knowledge and understanding of the research process.
Limited access to research.
Perceived cultural divide making it difficult to apply research evidence in practice.
Many medical practitioners are unfamiliar with much of the specific terminology and the often-impenetrable academic style that characterizes some research articles 4. Inability to understand the vocabulary has caused many problems with regards to use of research in practice. A questionnaire survey done among practitioners in UK showed that despite considerable variation in 302 general practitioners’ attitudes to the promotion of evidence based medicine, most were welcoming and agreed that it improved patient care 7. There was a low level of awareness of extracting journals, review publications, and databases relevant to evidence based medicine, and the major perceived barrier to its practice was lack of personal time. In their practice, only 20% of general practitioners had access to Medline or other bibliographic databases and 17% had access to the world wide web. Most had some understanding of the technical terms used in evidence based medicine, but less than a third felt able to explain to others the meaning of these terms . Respondents thought that the best way to move from opinion based practice towards evidence based medicine was by using evidence based guidelines or protocols developed by colleagues. The above studies and inferences regarding medical practitioners in the west well fit into the practitioners in south Asia. Research methodologies, though taught in undergraduate and post graduate programs, are not given the necessary stress they need to be given. Hence many doctors are not used to critically appraising research and bringing them into daily practice.
Lack of uniformity in health services:
Unlike countries which have a predominant state run health service or a predominant corporate health service, in south Asia, a diverse group of health care providers cater to the needs of the people. Primary health care at village level is provided by paramedical staff with good coverage in some areas and insufficient coverage in others. Research based practice by nursing and paramedical staff has become a reality in the west but there is a very long way to go to equip paramedical staff working in the field with research awareness. Further, south Asian countries have integrated traditional healthcare providers in providing primary care like the “dhais”. This unique environment is a real challenge in incorporating research based practice. A large mofussil crowd and a major share of the urban population is taken care by the streaming polyclinics and nursing homes run by doctor entrepreneurs who have virtually lost touch with research and its implications. Tertiary hospitals in major cities are in many cases run by business houses and use corporate business strategies and hi-tech specialization to create demand and attract those with effective demand or the critically vulnerable at increasing costs. Standards in some of them are truly world class and some are outstanding leaders in their areas. But given the commodification of health, high costs involved have prevented the middle class which forms the major chunk of the population to access this service. A whole gamut of alternative medicine practitioners, majority of whom are not properly trained also form a significant group of healthcare providers in the country though there are no exact statistics as to the percentage population catered by these very different groups. A research based practice is possible at tertiary centers which are inaccessible to the majority of population. Organizing and educating the Indian private practitioners is a challenging task. Creating awareness among public to choose the right service is essential to eliminate quack practice.
The ‘cuts’ practice:
Fee splitting is prohibited by the Indian medical council but still widely prevalent among practitioners. Many doctors run or partner a lab or a pharmacy. Some have equipments which they put into unjustified use. Many of the investigations ordered are unwarranted. The inadvertent use of certain diagnostic procedures definitely hamper the implementation of EBM.
Paucity of Specialist care in periphery:
Most of the young medical graduates shun general practice to become specialist of one or the other kind and settle down in cities. This has led to excessive competition in the urban areas leading to specialists working in junior positions for longer time with low remuneration and general practitioners treating most of the medical conditions which would otherwise require specialist attention in the periphery. Obviously, a specialist can easily be motivated towards research into his field and also a research based practice. Educating a general practitioner about everything is difficult.
The drug company game:
The big education gap between the urban institutions and peripheral individual practitioners has been efficiently utilized by the drug companies. In the name of education, manipulated medical information is delivered to the health practitioner with lots of compliments thereby convincing him to foster the sale of the respective drugs of the companies. In a study conducted among residents, physicians with access to drug samples were less likely to choose unadvertised drugs than residents who did not have access to samples and less likely to choose over-the-counter drugs. There was a trend toward less use of inexpensive drugs. The study concluded that access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.8. Another study showed that physicians who had requested that drugs be added to the formulary interacted with drug companies more often than other physicians; for example, they were more likely to have accepted money from companies to attend or speak at educational symposia or to perform research . Furthermore, physicians were more likely than other physicians to have requested that drugs manufactured by specific companies be added to the formulary if they had met with pharmaceutical representatives from those companies or had accepted money from those companies. 9 Organizations like “No Free Lunch” are spreading awareness on market influence on treatment practices and promoting evidence based practice.
Paucity of high Quality research:
For practicing EBM, good research work is the prime necessity. Regarding clinical research, some features in the Indian scenario are:
Failure to inculcate interest in research in medical school
Quality regulations in research being little leading to high rejection rates of Indian articles in international journals
Inability to publish and make research data online as many Indian journals are yet to become available online
Substandard quality maintenance of Indian journals and hence not being enlisted in Pubmed and similar databases
Many Level I and II studies should come from south Asian countries so that we can formulate our own guidelines for various diseases rather than following the western guidelines which may not be suitable for our population.



POSSIBLE SOLUTIONS
Initiating EBM awareness in medical colleges
Medical students are our asset. Promoting research and research based practice should start at medical schools. Curriculum planners and EBM specialists should interact to formulate a more practical teaching method for EBM at medical school level. Students in their pre final year may be given small assignments as to perform a critical analysis of a research paper. Post graduates should be trained in skills to search, retrieve, analyze and effectively use research data. Thesis work should be based on high quality research methodology.
Framing evidence based guidelines
The purpose of clinical guidelines is the same as the purpose for evidence-based practices—to translate research into practice, increase the effectiveness of treatment, provide a framework for collecting data about treatment, ensure accountability to funding sources, and to encourage some consistency in practice. One difference between clinical practice guidelines and evidence-based practices is that practice guidelines are not based on a single theoretical framework. Rather, practice guidelines are drawn from a wide variety of research literature, representing an eclectic collection of “things that work.”10 Evidence based practices are generally based on one theoretical approach and provide detailed descriptions of how to carry out the approach. Teachers have to be taught about the principles of EBM. Helping the institutions and professional bodies to come with treatment guidelines based on Evidence based practice would be the first step. Making these data reach every practitioner is the next step. When initiative is taken to formulate institution based guidelines, the lack of good research would highlight itself leading on to good studies and thereby treatment guidelines. In a study at an organizational level 11, the main issues identified were: (1) evidence-based practice was a low management priority (2) problems with dissemination (3) inadequate systems for personal and professional development (4) difficulties in the management of innovations (5) accessing evidence and resource constraints. The results of this study demonstrate that structures and cultures within organizations can be important barriers to evidence. Institutional policy makers have to be convinced and guidelines made according to the local necessity.
Collaboration with local bodies:
Organizations like Indian Medical Association and allied organizations in other countries can be roped in and meetings and training programs at regional, district and taluk levels to promote the concept of EBM can be organized. The attitude of Indian doctors towards EBM has not been extensively studied nevertheless, all taboos and prejudices should be properly addressed and programs modified according to the local needs. At the individual practice level, the main issues are motivation, a lack of clarity about roles and practice, and a culture of practice which emphasizes ‘routine’ patient care.
A particular situation can be taken and dealt with while teaching evidence based practice. For instance, a study about implementation of EBM in the treatment of hypertension was studied among practitioners12 several barriers were identified. These included:
Doubts about the applicability of trial data to particular patients;
Poor adherence of GPs to practice protocols;
Ageist attitudes of some GPs;
Effect of time pressure and financial considerations making the subject a low priority;
Absence of an effective computer system;
Absence of an educational mentor.
All participants demonstrated a very positive attitude to practice-based education. They also welcomed external audit data, which compared their performance with that of other practices. These barriers to change have to be addressed individually.
Effective training:
A preliminary study in the area or in the institute would be of great help in planning and disseminating the knowledge as training involves lot of resources and time. Lehman et al. 13 described an instrument for assessing program director and line staff readiness to change. It has two forms—one for leaders of the organization and one for treatment staff. The instrument has 115 items in four scales. Dwayne Simpson 14 proposed a four factor model of program change. Once a program has been assessed as ready to change, the process would begin with exposure, or training. If a practice is not acceptable to staff, clients, or the community at large, or it is too expensive, it will not be adopted no matter how effective it might be. Sorenson and colleagues 15 found that even when they provided on-site personal consultation about a new approach, 72% of agencies failed to fully implement the program. If they merely provided manuals, 96% failed to implement the program fully. Many providers and policy-makers have little or no training in research methods and some have negative attitudes about research.
Increasing accessibility:
Computer knowledge among Indian general practitioners needs to be studied upon and improved. Effective use of World Wide Web for information retrieval in short time needs to be taught. Providing basic computer knowledge at medical school is a viable option to produce computer literates in the first step towards EBM. Access to journals is a problem. The time spent by a medical practitioner per week for reading medical journals has to be studied. Promoting discussions about recent developments in the local forums have to be encouraged. Free access to medical information can go a long way in developing EBM in south Asian countries. Initiatives like HINARI do not include India. Recently, the National Medical library of India has come up with a scheme for free online access to many medical journals.
Checking the drug companies
Dr. G A Sarmiento commented “Failure to recognize industry’s control over orthopedic education is blindness of the worst kind.” The companies and the practitioners alike have to realize their duties. Governmental and professional regulations can help to some extent but the large part of change has to come from the practitioners.
Increasing resources:
Perhaps the greatest obstacle to implementing evidence-based practices is the lack of resources12. Resources include money, staff, computers, space, and materials, among others. Some of the ways to increase resources include:
Partnerships with researchers who will write grants to provide services.
Partnerships with businesses that may provide material goods, such as computers or training programs or photocopying.
Community volunteer programs
Designate one staff member as the grant-writer and send this person to workshops on grant writing.
Have fundraisers in the community.
Partner with media agencies or individual reporters to publicize the good work your agency does.
Involving Governments
State is responsible for the health of her subjects. Government and health planners have to realize the importance of providing the best care to the patient is possible with EBM and its practice in many instances can help in cutting down unwanted health expenses. The support from the state is necessary and extremely helpful when available, at every level of implementation of evidence based practice. Encouraging research at organization and individual level by incentives and scholarships, state sponsored Evidence Based Medicine cell in every region to work on the local barriers and ways to overcome them, effective organization of health care with regulation of private nursing homes, giving public health care role to corporate set ups, increasing public awareness and improving literacy and socio economic status of people, providing community access to health information can all help in building a society where medical care is based on a blend of clinical expertise and research based evidence.
Epilogue:
Evidence based medicine has come to stay and the south Asian healthcare environment poses stiff challenges to its implementation in this region but it is high time we realize its need act accordingly. Paucity of original research, lack of research awareness, mixed population of healthcare providers who have no regulations on updating themselves after their graduation, the fee splitting culture, the influence of drug companies, computer illiteracy, lack of access to EBM information, lack of resources and various other local and country specific factors are the major barriers. Identifying the barriers by properly planned study and addressing each one of them is the key to success. Thus said easily, the path ahead is difficult nevertheless not unconquerable. With young doctors looking into more towards evidence based practice, the future seems to be bright. 16

References:
Evidence-based medicine. A new approach to teaching the practice of medicine. Evidence-Based Medicine Working Group. JAMA. 1992;268:2420-5.

Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: How to practice and teach EBM. 1997. London: Churchill Livingston.
Hurwitz SR, Tornetta,P, Wright JG. An AOA Critical Issue How to Read the Literature to Change Your Practice: An Evidence-Based Medicine Approach. J Bone Joint Surg Am. 2006;88:1873-1879.
Davidoff F, Haynes B, Sackett D, Smith R. Evidence based medicine: a new journal to help doctors identify the information they need. BMJ 1995;310:1085-6.
McSherry R, Artley A, Holloran J. Research Awareness: An Important Factor for Evidence-Based Practice? Worldviews on Evidence-Based Nursing 2006; 3(3):103–115.
McSherry R. What do registered nurses and midwives feel and know about research? Journal of Advanced Nursing, 1997;25(5): 985–998.
Estabrooks C.A. The conceptual structure of research utilization. Research in Nursing and Health,1999;22(3):203–216.
Glacken M. Research and development in Northern Ireland Trust. Nursing Standard,2002;16(32): 33–37.
McColl A, Smith H, White P, Field J. Information in practice .General practitioners’ perceptions of the route to evidence based medicine: a questionnaire survey . BMJ 1998; 316:361-365
Adair RF, Holmgren LR Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005 Aug;118(8):881-4.
Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies. A controlled study of physicians who requested additions to a hospital drug formulary. JAMA. 1994 ;271(9):684-9.
Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencies ,Iowa PIC, Spring, 2003
Newman M, Papadopoulos I, Sigsworth J, Barriers to evidence-based practice. Clinical Effectiveness in Nursing .1998:2 (1):11-18.
Cranney M, Warren E,, Barton S, Gardner K, Walley T. Why do GPs not implement evidence-based guidelines? A descriptive study. Family Practice 18(4), 359-363.
.Simpson, D. A conceptual framework for transferring research to practice. Journal of Substance Abuse Treatment, 2002;22:171-182.
Lehman, W., Greener, J., & Simpson, D. Assessing organizational readiness for change. Journal of Substance Abuse Treatment, 2002;22: 197-209.
Sorenson, J., Hall, S., Loeb, P., Allen, T., Glaser, E., & Greenberg, P. Dissemination of a job seekers’ workshop to a drug treatment program. Behavior Therapy, 1988;19: 143-155.
Poolman,RW , Sierevelt, IN, Farrokhyar FJ. Mazel A, Blankevoort L, Bhandari M. Perceptions and Competence in Evidence-Based Medicine: Are Surgeons Getting Better? A Questionnaire Survey of Members of the Dutch Orthopaedic Association. J Bone Joint Surg Am. 2007;89:206-215.