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