We have shown that a multifaceted intervention designed to teach EBM skills and implement evidence resources significantly improved practice patterns in a district general hospital. After the EBM intervention, more patients were prescribed therapies proven to be efficacious in randomized trials, and the trials supporting these therapies were significantly more likely to be high quality than before the EBM intervention. The observed absolute improvement of 13% exceeds the 10% absolute improvement which has long been accepted as the minimal clinically important difference for studies of educational interventions.7
The degree to which practice on the medical inpatient units at this district general hospital was evidence based after the EBM intervention is very similar to that reported for medical inpatient units at university-affiliated tertiary care hospitals with attending physicians holding postgraduate degrees in clinical epidemiology. For example, using the same definition we did, 82% of primary interventions were deemed to be evidence based at the John Radcliffe Hospital in Oxford, United Kingdom and 84% at the Ottawa General Hospital in Ottawa, Canada.6,8
This includes 53% (and 57%, respectively) of primary interventions which were deemed to be class 1 (i.e., supported by RCTs). Thus, we have shown that the attainment of evidence-based practice is indeed possible in busy clinical settings after implementation of appropriate resources and teaching of EBM skills.
The results of two recent randomized trials suggest there may be benefit to EBM training although differences in the formulation of the intervention make it difficult to compare with the current study.9,10
In the first study, information management was compared with training in EBM for secondary prevention of cardiac disease in primary care.9
The combination of these interventions showed some improvement in management of cholesterol. However, it appears that the study intervention was focused on searching and retrieving evidence from the Internet and medline
around this particular condition and did not include education on formulating questions, applying the evidence, or assessing our performance. Moreover, the intensity of the intervention is unclear. The second study evaluated the impact of an EBM educational intervention among public health workers but did not report impact on actual behaviors.10
However, our study is a before/after case series and does not carry the same weight as a randomized trial. Ideally, to complete a methodologically rigorous study of EBM, we would aim to expose “control” clinicians to an evidence-poor teaching intervention and allow them to become out of date and unaware of potentially life-saving evidence accessible to and known by the evidence-based clinicians in the experimental group. However, this approach is not ethical and alternative designs must be explored. We were unable to identify an appropriate control site with the same patient, house staff, and attending physician mix and which had the same informatics infrastructure. This hospital had a fully integrated information support system as one of two nationally funded pilot sites. And, we were unable to do an interrupted time series given the time constraints due to house staff rotation.
Our choice of study design limits the inferences that should be drawn from this study. Thus, while our study suggests that EBM training does meaningfully impact on clinical decision making, randomized trials of EBM teaching are clearly needed and one of us (SES) has embarked on just such a study. This randomized trial of family physicians has been designed to determine whether an online EBM educational intervention can change behavior and clinical outcomes. Our study may also be criticized for reporting on process measures (therapy prescribed) rather than clinical outcomes such as mortality. However, we chose to focus on process measures as they are more sensitive indicators of quality of care than changes in clinical outcomes which take months or years to manifest.11
Finally, we do not have any data on the frequency with which the various evidence resources were accessed by the clinicians at Queen's Hospital. However, other investigators have shown that if you provide evidence resources in a convenient and readily accessible format, clinicians with training in EBM will use them.12,13
In summary, we have demonstrated that the practice of clinicians in a district general hospital changed in a statistically significant and clinically meaningful way after completion of an EBM training course and provision of evidence resources. The implications of our study are further amplified by evidence that clinicians trained in EBM are more likely to remain up to date for longer after their training than clinicians without EBM training.14
Given that surveys of frontline clinicians confirm widespread enthusiasm for EBM and a desire to learn the key skills such as evidence retrieval and critical appraisal,15–19
we believe that training in the practice of EBM should remain a key component of undergraduate and postgraduate education. Proponents of knowledge translation have advocated that changing behavior requires comprehensive approaches directed toward patients, physicians, managers, and policy makers.20
The results of this study suggest that a multifaceted approach to teaching EBM can change behavior.