dissemination and usage of an online compendium in four european countries rabady, kunnamo g-i-n...

Dissemination and usage of an online Dissemination and usage of an online compendium in four European countriescompendium in four European countries

Rabady, Kunnamo Rabady, Kunnamo G-I-N Lisbon 2009 G-I-N Lisbon 2009

Evidence can cross borders – Evidence can cross borders – can guidelines do the same?can guidelines do the same?

The ProjectThe Project

• Developed in Finland, disseminated Developed in Finland, disseminated internationally, translated into several internationally, translated into several languageslanguages

• Adaptation and online version for German Adaptation and online version for German speaking countriesspeaking countries

• ““Point-of-care” - projectPoint-of-care” - project

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

The AimThe Aim• To learn about dissemination and usage To learn about dissemination and usage

by comparison:by comparison:– Same projectSame project– Different health systemsDifferent health systems– Different methods of disseminationDifferent methods of dissemination– Different preconditionsDifferent preconditions

• Methods:Methods:– Log filesLog files– User surveyUser survey

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Comparing DisseminationComparing Dissemination

Overall Usage

0

20

40

60

80

100

120

Finland Austria Switzerland Germany

country

per

cen

tag

e o

f G

Ps

wit

h

acce

ss

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Use of Physician´s databases in Finland

Numberof guidelinesopened approx.12 million/year (2009 estimated)

Comparing UsageComparing Usage

articles opened per user 2008

0

50

100

150

200

Finland Austria Germany Switzerland

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Web-based survey May – June 2009

• 2800 physicians and 500 medical students were e-mailed a web-based (Webropol™) questionnaire in Finland and in the German-speaking countries

• Response rate 18 %

0 10 20 30 40 50

Not using

Once a month

Once a week

A few times a week

Once a day

Several times a day

Open all the time

German-speaking

Finland

Frequency of EBMG use German-speaking countries vs. Finland

Answers German-speaking countries vs. Finland

EBM Guidelines…

0 20 40 60 80 100

Influencespractice

Time-saving

Lessconsultation

Reliable

Independent

Up-to-date

Easy to use

Evidence-based

Practical

German-speakingFinland

Use by time of the day and day of the weekUse by time of the day and day of the week

Searches in course of time 4 09

0

20

40

60

80

100

120

140

8 10 12 14 16 18 20 22time of day

nu

mb

er o

f se

arch

es

Wochentags

Wochenende

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

German-speaking

Finland

• In spite of differences in working In spite of differences in working conditionsconditions– Number of patient contactsNumber of patient contacts– Referral thresholdsReferral thresholds– Role of primary careRole of primary care

• there is little difference in the number there is little difference in the number of articles opened per user dailyof articles opened per user daily

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Some background for the discussionSome background for the discussion

• Finland provides free access for every Finland provides free access for every health professional in public health systemhealth professional in public health system

• In Finland EBMG is integrated in a Health In Finland EBMG is integrated in a Health portal with 70 000 documentsportal with 70 000 documents

• Few German-speaking doctors are online Few German-speaking doctors are online during consultationsduring consultations

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

• German-speaking countriesGerman-speaking countries– ca 27.000 copies of the book sold within 3 ca 27.000 copies of the book sold within 3

yearsyears– Few hundred online accesses sold over two Few hundred online accesses sold over two

yearsyears

• Main source of information for physicians Main source of information for physicians in Finlandin Finland– 77 % electronic databases77 % electronic databases– 23 % books and journals23 % books and journals

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

QuestionsQuestions

• What are the reasons for variance of What are the reasons for variance of clinical practice in different countries? clinical practice in different countries? Which differences are real?Which differences are real?

• Which factors influence the acceptability of Which factors influence the acceptability of guidelines that have originally been guidelines that have originally been produced in another country?produced in another country?

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

articles opened per login

0

1

2

3

4

5

6

Austria Germany Switzerland

opened per login

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

What‘s in Common?What‘s in Common?

Most read articles 1.1.2007 - 20.8.09

Lyme-Borreliose 1896

Antibiotikatherapie 1253

Impfungen 1066

Therapie beim Harnwegsinfekt 1041

Halsschmerzen und Tonsillitis 1010

Herpes zoster 830

Tonsillitis und Pharyngitis Kind 788

Tiefe Venenthrombose 771

Akute Otitis beim Kind 738

Diabetes mellitus: Definition, Differentialdiagnostik 725

Lumbalgie 725Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

What`s in Common - DiscussionWhat`s in Common - Discussion

• Those who have it, use it.Those who have it, use it.• EbM-Guidelines are being used mainly during EbM-Guidelines are being used mainly during

office hours.office hours.• Frequent and typically GP - topics are frequently Frequent and typically GP - topics are frequently

searched for.searched for.

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

ConclusionConclusion

• „„Guideline adaptation“ seems to imply the Guideline adaptation“ seems to imply the necessity to adapt dissemination methods.necessity to adapt dissemination methods.

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009

Health Gate a comprehensive health portal in Finland

• Contains over 70 000 documents, including e.g. e-books, medical journals, pharmaceutical databases and guidelines.

• Can be reached by almost all practising physicians, but also by other health care professionals

• Evidence-Based Medicine Guidelines (EBMG) is an essential part of ”Health gate”

• EBMG contains over 1 000 regularly updated guidelines • Main target groups are primary care and outpatient clinics• Over 400 specialists participate in EBM Guidelines production

Search engines

ICD-10

Drug information

News

Bookshop

Patient instructions

Specialist societiesCME

Dictionaries

Job vacancies

eBooks

Duodecim Medical Journal

Journals

Guidelines and evidence

Health Gate for health care professionals

Frequency of ”Health Gate” use

Answers by age-groups below or over 50

EBM Guidelines…

0 20 40 60 80 100

Influencespractices

Helps intime-saving

Lessconsultation

ReliableIndependent

Up-to-dateEasy

Evidence-based

Practical

50 and over n = 184Below 50 n = 359

Answers GP:s vs. other specialists

Conclusions

• In all groups, the impression of EBMG quality was high (over 90% considered it very good or good)

• Younger doctors, non-specialists and GP:s found it more useful in everyday practice

• There were practically no negative opinions: most answers that were not ”very good” or ”good” were in the ”cannot say” category

This all sounds good…

• Too good?– Can we rely on web-based questionnaire results and

feedback?– How should we complement this information?

Pros of web-based questions

• Easy, quick and cheap to do• A lot of people can be reached in a short time• Can be answered and returned quickly from target group

perspecti ve

• But

Cons of web-based questionnaires

• Using Internet you catch people who use Internet• Too many e-mails and questionnaires may cause frustration

and select people who are willing to reply• Formulating questions right you get answers you like to get

(as with any questionnaire)

Web-based questions can be used to…

• Identify major problems • Get an impression of general opinion• Reach a large population and get many answers = lots of

quantitative data• Marketing purposes

• But• For more precise and scientificically sound results,

complementary qualitative methods should be used like e.g.– Video-taped appointments– Focus group interviews

What`s the difference?What`s the difference?

• Germany has by far the lowest percentage of users, Germany has by far the lowest percentage of users, compared with Austria and Switzerlandcompared with Austria and Switzerland

• German doctors open more articles per user and login German doctors open more articles per user and login than any of the othersthan any of the others

Rabady, Kunnamo Lisbon 2009Rabady, Kunnamo Lisbon 2009