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The use of clinical practice guidelines (CPGs) saves time and provides the highest level of evidence, allowing busy ophthalmologists to make the best clinical decisions in a short amount of time. The aim of this study is to evaluate Iranian ophthalmologists’ knowledge and attitudes toward evidence-based medicine (EBM), and knowledge of CPGs. We performed a cross-sectional survey during the Annual Congress of the Iranian Society of Ophthalmology (November 2011). We administered 2 questionnaires regarding ophthalmologists’ attitudes towards EBM and self-reported clinical practices to a self-selected sample of ophthalmologists who volunteered to be surveyed. We employed descriptive statistics and unadjusted associations to describe the results. Of 556 attendees, 100 ophthalmologists responded to the first questionnaire, and 60% of them answered the second questionnaire. Although 83% had heard about EBM, only 11% knew what EBM was. Ninety-five percent of respondents believed in evidence-based ophthalmology training. Few understood EBM terminology. More than 60% of ophthalmologists surveyed had no familiarity with the Cochrane Library, MDConsult or Turning Research Into Practice (TRIP databases. Of the ophthalmologists surveyed, 26% implemented guidelines for problem solving, and 59% utilised the internet for finding clinical guidelines. The mean proportions of correct response to evidence-based cataract and glaucoma management questions were 68 and 56, respectively. Iranian ophthalmologists had a fair to poor knowledge but good attitudes towards EBM. Improving evidence-based knowledge and attitudes may be a component of improving Iranian ophthalmologists’ clinical practices.
Acknowledgments
This study is granted by Iranian Evidence Based Medicine Center of Excellence, Tabriz University of Medical Sciences, and their support is greatly appreciated. The authors also thank the members of the Iranian Society of Ophthalmology.
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Introduction
Clinical decision-making plays a major role in daily practice, and decisions are generally based on physicians’ experience and knowledge, their consultation with colleagues and reference to textbooks or other components.1 ,2 Given that evidence-based medicine (EBM) involves the integration of individual clinical expertise with the best available evidence,3 one of the most important components in decision-making could be familiarity with EBM. Therefore, learning and understanding EBM could improve the capabilities of clinicians, and enable them to use the best evidence in decision-making. However, according to the literature, it seems that the implementation of EBM among physicians in developing countries is still low. One reason for this might be unfamiliarity with the concept of EBM and best evidence,4–9 in addition to lack of time for familiarisation with EBM, especially among surgeons.10–14
According to the Oxford Center for Evidence-Based Medicine, information resources are located on five levels of evidence.15 As the clinical practice guidelines (CPGs) and their recommendations are developed based on a high level of evidence, they are considered to be the highest quality and highest level of evidence.16 The Institute of Medicine (IOM) defines CPGs as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances”.17 Thus, CPGs play a major role in practice and policy-making and, in order to achieve desirable health outcomes, developing and implementing CPGs is necessary.18 ,19
Clinical guidelines are categorised as summaries in the 5S pyramid of evidence resources that integrate best available evidence,16 and they are an appropriate go-to tool for busy clinicians to quickly make the best decision based on guideline recommendations. Ophthalmologists have busy practices, as do most surgeons, and they have limited time to stay current within the field; therefore, the implementation of evidence-based guidelines is an optimal solution to lead them to best decision-making. Studies in past decades anticipated the need for methodological and evidence-based clinical guidelines for ophthalmologists.20 ,21
There are few studies of clinical guideline implementation among ophthalmologists,22–25 and it is not clear whether there is a relationship between evidence-based knowledge and evidence-based practice. We designed the current study to evaluate Iranian ophthalmologists’ knowledge and attitudes toward EBM, and to describe ophthalmologists’ knowledge about EBM and their self-reported clinical practices.
Methods
We used a cross-sectional, questionnaire-based survey during the Annual Congress of the Iranian Society of Ophthalmology (November 2011). We designed two questionnaires: the first questionnaire was a self-administered questionnaire in the Persian language, used in previous research (see online supplementary appendix).26 Two experts in the field of ophthalmology and EBM developed the second questionnaire, which included clinical scenarios based on the relevant evidence-based clinical guidelines related to the management of patients with cataract or glaucoma.27 ,28 The guidelines were searched and selected from clinical guideline databases including PubMed, Guideline International Network (GIN), National Guideline Clearinghouse (NGC), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), the WHO and other related websites.
After group discussions and consensus, the authors and experts in the Ophthalmology Department of Tabriz University of Medical Sciences selected 13 scenarios designed to assess ophthalmologists’ attitudes towards the diagnosis and management of cataract and glaucoma. We asked ophthalmologists to choose the best option regarding each scenario, and compared these with the best choice recommended by selected clinical guidelines.
All 556 attending ophthalmologists in the Annual Congress of the Iranian Society of Ophthalmology were invited to participate in this study through announcements in the congress exhibition. We explained the aim of study to all the participants and considered their interest in participating in the study as informed consent. We asked participants to complete the first questionnaire and, after completion of the first, we distributed the second. All personal information was kept confidential. The study was approved by the local ethical committee of Iranian Evidence Based Medicine Center of Excellence.
Data are shown as mean±SD. We generated descriptive statistics for all parts of the questionnaire and used χ2 tests for data analysis. We analysed the data using SPSS V.16 (SPSS Inc, Chicago, Illinois, USA). A p value <0.05 was considered significant.
Results
One hundred of 556 ophthalmologists agreed to fill out the first questionnaire, while 60 (60%) of the hundred answered the second questionnaire. Fifty-five (55%) respondents were male and 45 (45%) were female. Thirty-two were younger than 40 years, 33 were 41–50 years, and 27 were older than 50 years. More than half the respondents (54%) had more than 15 years’ experience in ophthalmology (figure 1). The proportion of participants in each category of faculty members, health system employees and non-faculty groups, were similar (37%, 33% and 30%, respectively).
Frequency of ophthalmologist's years of experience.
Knowledge and attitude towards EBM and clinical guidelines
Of the 100 respondents, 83 had heard about EBM but only 11 knew what EBM was. Ninety-five believed that ophthalmology training should be based on EBM. Regarding familiarity with EBM terminology, more than half the respondents had heard about it, but <10% could explain these concepts to others (figure 2). A dummy question (about something we called ‘SNN’) was asked to evaluate the value of the responses and, surprisingly, 67% of respondents reported they knew about this term. Regarding the implementation of information sources for problem solving, ophthalmologists preferred textbooks as a first priority (45%), internet resources as a second priority (34%) and clinical guidelines as a third priority (26%). Meanwhile, 53 respondents frequently used the internet for practice, while 59 respondents reported using the internet to find ophthalmology clinical guidelines, and 31 respondents used the internet primarily to find clinical guidelines.
Ophthalmologist's familiarity with EBM terminology. EBM, evidence-based medicine; RR, relative risk; ARR, absolute relative reduction; NNT, number needed to treat; SNN, dummy term*.
Utilisation of databases related to EBM
Utilisation of databases and search engines for information retrieval differed among respondents (table 1). Google and PubMed were the most popular online resources (95% and 59% users, respectively), while more than 60% of respondents had no familiarity with the Cochrane Library, MDConsult, the Turning Research Into Practice (TRIP) database or EMBASE. Unfamiliarity with Google Scholar was also remarkable (52%).
Use of databases and search engines
Daily practice of the ophthalmologist based on CPGs
Sixty respondents answered the questions on the second questionnaire (scenarios of evidence-based guidelines). Twenty-eight (47%) were faculty members and 32 (53%) were non-faculty. Table 2 shows the percentage of correct responses to each scenario among the faculty and non-faculty members. Non-faculty members’ correct response percentages were generally higher than faculty members’, but there was no significant difference between faculty and non-faculty members’ correct answers to each question, with the exception of questions 3 and 4 (Q3: χ2=6.56, df=1, p=0.01 and Q4: χ2=4.05, df=1, p=0.04), for which non-faculty scored significantly higher. Overall, mean scores of cataract and glaucoma questions per respondent were calculated based on correct proportion of responses to each (Cataract: 67.61±21.01; Glaucoma: 55.55±19.08).
Frequency of correct response rate to scenarios by faculty and non-faculty respondents
Discussion
In this study, ophthalmologists’ reported attitudes towards EBM were relatively good. However, only one-tenth of ophthalmologists were familiar with the EBM concept and the rest had only heard about EBM, and acknowledged the benefits of training in EBM. Studies of Iran4 ,5 ,10 ,29 reported positive attitudes towards the necessity of EBM training, as well. All studies mentioned show the orientation of physicians about the importance of learning and teaching EBM for practice. It seems that the implementation of EBM in medical curricula would be welcomed, as concluded in recent literature.30 ,31
Less than 10% of ophthalmologists understood EBM terminology completely. On the other hand, since respondents’ answer rate to the dummy term (SNN) was nearly equivalent (66% somewhat familiar) with other terms, it seems that answers to other questions in EBM terminology could reflect social desirability bias—the respondents’ wish to appear knowledgeable. Other studies show a different result and a higher rate of EBM terminology awareness by physicians and surgeons,4 ,32–34 except for Maaskant et al, whose results show that <10% understood number needed to treat among participants.35 As understanding EBM-related terms is indispensable for critical appraising and well-advised decision-making, training in these concepts seems necessary, and learning and teaching these terms will be easy with EBM training principles. A second option would be for clinicians to use preappraised resources such as evidence summaries and practice guidelines for decision-making, which needs no more knowledge in critical appraisal.
Ophthalmologists had little familiarity with evidence databases and Google Scholar, while Google use was 95%. The authors’ previous study on university faculties and clinical residents had similar results.24 Since PubMed, MDConsult and TRIP have specific filters for guidelines, we recommend introducing these filters to practitioners and training them in order to facilitate ‘finding the best clinical practice guidelines’. Although the Cochrane library does not contain clinical guidelines, it does contain five databases, including systematic reviews,36 which are at the first level of evidence and are the best resources for developing CPGs. Studies for finding best evidence found on Google, compared with other databases, show a competitive retrieval rate for Google37 ,38 and, considering the high popularity of Google, training physicians on how to use proper keywords in googling could lead them to comprehensive clinical guideline retrieval.
Surveyed ophthalmologists demonstrated a reasonable knowledge of clinical practices for managing cataracts, with an overall 68% rate of correct answers, but less for glaucoma questions, with 56% correct. Our previous study shows training of cataract management in the Iranian ophthalmology curriculum is highlighted, which echoes this difference.39
Overall, respondents’ reasonable rate of correct answers to cataract and glaucoma questions shows that they are aware of new developments and updates in this field. Regarding the high use of the internet for finding ophthalmology clinical guidelines by surveyed ophthalmologists (59%), building and enhancing national, user-friendly CPG databases could have a positive impact on their potential knowledge and practice. Other studies also reported such a positive attitude towards clinical guidelines.10 ,23 ,40 ,41 A study in the UK shows that adherence to guidelines for initial assessment and choice of treatment and drug by ophthalmologists is good.24 However, the rate of guideline implementation in practice is not acceptable and, according to Ishii,42 there is a clinical gap between knowledge and practice. As well-prepared CPGs are in the highest level of the evidence pyramid, training of evidence-based practice and implementing CPGs in ophthalmology curricula is crucial. This need was identified in Baradaran-Seyed et al’s43 study as one of the main barriers for implementation of the guidelines in Iran.
This study had some limitations. Only 100 of 550 attending ophthalmologists in the Iranian Society of Ophthalmology participated in the survey, and the results may not be generalisable to all Iranian ophthalmologists. Further studies are needed to describe the quality of care among ophthalmology departments, and to assess whether EBM knowledge and attitudes are associated with practices. For this reason, a cohort study for assessing the benefits of clinical guideline implementation in patient care is suggested. In this study, we could not evaluate some variables including sex, age, work experience and academic membership, due to data scattering.
This study provides good background knowledge about self-reported practice of Iranian ophthalmologists and their enthusiasm towards evidence-based practice.
Conclusion
Through this research, we identified a poor to fair level of knowledge of EBM but good knowledge and attitudes towards evidence-based practice of Iranian ophthalmologists. This finding is expressed in their self-reported evidence-based daily practice. Teaching EBM and how to implement clinical guidelines in the ophthalmology curriculum may eliminate some of the barriers to evidence-based practice.
Acknowledgments
This study is granted by Iranian Evidence Based Medicine Center of Excellence, Tabriz University of Medical Sciences, and their support is greatly appreciated. The authors also thank the members of the Iranian Society of Ophthalmology.
References
Footnotes
Contributors MG and SH designed the study, HM and AM collected the data, MG and FS-G conducted the data analysis, and the article was written by SH and FS-G, and critically edited by AM and FS-G. All the authors read and approved the final manuscript.
Funding This study is funded by Iranian Evidence Based Medicine Center of Excellence.
Competing interests None declared.
Ethics approval All the authors declare that all steps of the study approved by the local ethical committee of Iranian Evidence Based Medicine Center of Excellence and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The two questionnaires regarding ophthalmologists’ attitudes towards EBM and self-reported clinical practices are available from the authors on request.