Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings

Feasibility, acceptability and impact of a clinical decision support tool among primary care providers in an urban, rural and remote site in the Philippines

INTRODUCTION

Strengthening primary care helps address health inequities that continue to persist in the Philippines. The Philippine Primary Care Studies pilot-tested interventions to improve the primary care system. One intervention was the provision of a free subscription to an electronic decision support application called UpToDate (UTD) for primary care providers (PCPs), including doctors, nurses, midwives and community health workers (CHWs). This study aimed to (1) assess the feasibility of using UTD as information source for PCPs in urban, rural and remote settings, (2) determine the acceptability of UTD as an information source for PCPs and (3) examine the impact of UTD access on PCP clinical decision-making.

METHODS

Four focus group discussions (FGDs) and two key informant interviews (KII) were conducted to gather insights from 30 PCPs. Thematic analysis through coding in NVivo V.12 was done using the technology acceptance model (TAM) as a guiding framework.

RESULTS

All PCPs had positive feedback regarding UTD use because of its comprehensiveness, accessibility, mobility and general design. The participants relayed UTD's benefit for point-of-contact use, capacity-building and continuing professional development. PCPs across the three sites, including CHWs with no formal medical education, were able to provide evidence-based medical advice to patients through UTD. However, external factors in these settings impeded the full integration of UTD in the PCPs' workflow, including poor internet access, unstable sources of electricity, lack of compatible mobile devices and the need for translation to the local language.

CONCLUSION

UTD was a feasible and acceptable clinical decision support tool for the PCPs. Factors affecting the feasibility of using UTD include technological and environmental factors (ie, internet access and the lack of translation to the local language), as well as the organisational structure of the primary care facility which determines the roles of the PCPs. Despite the difference in roles and responsibilities of the PCPs, UTD positively impacted decision-making and patient education for all PCPs through its use as a point-of-contact tool and a tool for capacity-building.

Implementing point-of-care medical information systems into trauma and general surgeon practice in a middle-income country: a qualitative study utilizing the Consolidated Framework for Implementation Research

BACKGROUND

Point-of-care medical information systems (POCMIS) can provide an efficient and effective means of strengthening health systems globally through their encouragement of continued medical education. Using the Consolidated Framework for Implementation Research (CFIR) as a guide, this research provides suggestions for improved implementation of POCMIS in low- and middle-income countries informed by an intervention implemented across public and military hospitals in Lima, Peru.

METHODS

Analysis is based on qualitative interviews conducted with 12 Peruvian surgeons across eight public hospitals and one military hospital who received an intervention that provided free access to UpToDate and introduced Google Translate. The post-intervention interviews were transcribed, translated, and analyzed for themes overlapping with CFIR constructs to expose barriers to implementation and suggestions for improved implementation of future interventions.

RESULTS

Barriers included a lack of seniority buy-in and engaged leadership, an overabundance of personal preferences for multiple POCMIS, and a culture of assumption that inhibited open communication regarding access to and use of POCMIS. Suggestions for improved implementation focused on the adaptation of the intervention. Namely, surgeons discussed regionally-specific adaptations as well as adaptations specific to their surgical specialty including visual, rather than written, representation of the information available via POCMIS.

CONCLUSIONS

Results indicate necessary adaptations for implementing interventions including POCMIS in LMICs, mimicking much of the implementation science literature on intervention adaptation. In addition to explicit suggestions provided by surgeons, we also suggest actionable steps to adapt to barriers identified in our data. Rapid assessment procedures (RAP) are one established methodological technique useful for assessing organization culture prior to implementation, allowing for necessary cultural adaptations. Dynamic adaption process (DAP) is another useful and established method that breaks implementation into four phases allowing for adaptations based on the initial assessment of the intervention site.

Barriers and facilitators to use of a digital clinical decision support tool: a cohort study combining clickstream and survey data

OBJECTIVES

This research aimed to understand the barriers and facilitators clinicians face in using a digital clinical decision support tool-UpToDate-around the globe.

DESIGN

We used a mixed-methods cohort study design that enrolled 1681 clinicians (physicians, surgeons or physician assistants) who applied for free access to UpToDate through our established donation programme during a 9-week study enrolment period. Eligibility included working outside of the USA for a limited-resource public or non-profit health facility, serving vulnerable populations, having at least intermittent internet access, completing the application in English; and not being otherwise able to afford the subscription.

INTERVENTION

After consenting to study participation, clinicians received a 1-year subscription to UpToDate. They completed a series of surveys over the year, and we collected clickstream data tracking their use of the tool.

PRIMARY AND SECONDARY OUTCOME MEASURES

(1) The variation in use by demographic; (2) the prevalence of barriers and facilitators of use; and (3) the relationship between barriers, facilitators and use.

RESULTS

Of 1681 study enrollees, 69% were men and 71% were between 25 and 35 years old, with the plurality practicing general medicine and the majority in sub-Saharan Africa or Southeast Asia. Of the 11 barriers we assessed, fitting the tool into the workflow was a statistically significant barrier, making clinicians 50% less likely to use it. Of the 10 facilitators we assessed, a supportive professional context and utility were significant drivers of use.

CONCLUSIONS

There are several clear barriers and facilitators to promoting the use of digital clinical decision support tools in practice. We recommend tools like UpToDate be implemented with complementary services. These include generating a supportive professional context, helping clinicians realise the tools' use and working with health systems to better integrate digital, clinical decision support tools into workflows.

Scientific literacy and preferred resources used by Latin American medical students during the COVID-19 pandemic: A multinational survey

Background: This study aims to identify the preferred sources for acquiring knowledge about COVID-19 and to evaluate basic knowledge on critical scientific literature appraisal in students from medical schools located in Spanish speaking countries in Latin America. 

Methods: We designed an online survey of 15 closed-ended questions related to demographics, preferred resources for COVID-19 training, and items to assess critical appraisal skills. A snowball method was used for sampling. We conducted a descriptive analysis and Chi-squared tests to compare the proportion of correct identification of the concept of a preprint and a predatory journal when considering a) self-perceived level of knowledge, b) public vs private school, c) inclusion of a scientific literature appraisal subject in the curriculum, and d) progress in medical school.

Results: Our sample included 770 valid responses, out of which most of the participants included were from Mexico (n=283, 36.8%) and Ecuador (n=229, 29.7%). Participants preferred using evidence-based clinical resources (EBCRs) to learn more about COVID-19 (n=182, 23.6%). The preferred study design was case report/series (n=218, 28.1%). We found that only 265 participants correctly identified the concept of a preprint (34.4%), while 243 students (31.6%) correctly identified the characteristics of a predatory journal. We found no significant differences in the proportion of correct answers regardless of the self-perceived level of knowledge, progress in medical school, or scientific literature critical appraisal classes.

Conclusion: This study is novel in its approach of identifying sources of knowledge used by Latin American medical students and provides insights into the need to reinforce training in critical appraisal of scientific literature during medical school.

Understanding the needs of low-income countries: how urologists can help

Delivering urological humanitarian aid to countries with greater need has been provided by urologists associated with British Association of Urological Surgeons (BAUS) Urolink over the last 30 years. Urolink has realised the need to understand where that need is geographically, what tangible help is required, and how assistance can be delivered in the most ethically appropriate way. The World Bank stratification of countries by per capita gross national income has helped in the identification of low-come countries or lower-middle-income countries (LMICs), the vast majority of which are in sub-Saharan Africa. The medical and socioeconomic needs of those country's populations, which constitute 17% of the global community, are substantially different from that required in higher income countries. More than 40% of sub-Saharan Africa's population is aged <14 years, it has a substantially reduced life expectancy, which influences the type of pathologies seen, and perinatal complications are a major cause of morbidity for both mother and child. There is a significant problem with the availability of medical care in these countries and almost a third of global deaths have been attributed to the lack of access to emergency and elective surgery. Urologically, the main conditions demanding the attention of the very few available urologists are congenital anomalies, benign prostatic hypertrophy, urolithiasis, urethral stricture, and pelvic cancer. The management of these conditions is often substantially different from that in the UK, being limited by a lack of personnel, equipment, and access to geographically relevant guidelines appropriate to the healthcare environment. Assisting LMICs to develop sustainable urological services can be helped by understanding the local needs of linked institutions, establishing trusting and durable relationships with partner centres and by providing appropriate education that can be perpetuated, and disseminated, across a region of need.

Segmenting clinicians’ usage patterns of a digital health tool in limited resource settings: methodology and initial results (Preprint)

Background

Evidence-based digital health tools allow clinicians to keep up with the expanding medical literature and provide safer and more accurate care. Understanding users’ online behavior in low-resource settings can inform programs that encourage the use of such tools. Our program collaborates with digital tool providers, including UpToDate, to facilitate free subscriptions for clinicians serving in low-resource settings globally.

Objective

We aimed to define segments of clinicians based on their usage patterns of UpToDate, describe the demographics of those segments, and relate the segments to self-reported professional climate measures.

Methods

We collected 12 months of clickstream data (a record of users’ clicks within the tool) as well as repeated surveys. We calculated the total number of sessions, time spent online, type of activity (navigating, reading, or account management), calendar period of use, percentage of days active online, and minutes of use per active day. We defined behavioral segments based on the distributions of these statistics and related them to survey data.

Results

We enrolled 1681 clinicians from 75 countries over a 9-week period. We based the following five behavioral segments on the length and intensity of use: short-term, light users (420/1681, 25%); short-term, heavy users (252/1681, 15%); long-term, heavy users (403/1681, 24%); long-term, light users (370/1681, 22%); and never-users (252/1681, 15%). Users spent a median of 5 hours using the tool over the year. On days when users logged on, they spent a median of 4.4 minutes online and an average of 71% of their time reading medical content as opposed to navigating or managing their account. Over half (773/1432, 54%) of the users actively used the tool for 48 weeks or more during the 52-week study period. The distribution of segments varied by age, with lighter and less use among those aged 35 years or older compared to that among younger users. The speciality of medicine had the heaviest use, and emergency medicine had the lightest use. Segments varied strongly by geographic region. As for professional climate, most respondents (1429/1681, 85%) reported that clinicians in their area would view the use of a online tool positively, and compared to those who reported other views, these respondents were less likely to be never-users (286/1681, 17% vs 387/1681, 23%) and more likely to be long-term users (655/1681, 39% vs 370/1681, 22%).

Conclusions

We believe that these behavioral segments can help inform the implementation of digital health tools, identify users who may need assistance, tailor training and messaging for users, and support research on digital health efforts. Methods for combining clickstream data with demographic and survey data have the potential to inform global health implementation. Our forthcoming analysis will use these methods to better elucidate what drives digital health tool use.

Better evidence: prospective cohort study assessing the utility of an evidence-based clinical resource at the University of Rwanda

OBJECTIVE

Evidence-based clinical resources (EBCRs) have the potential to improve diagnostic and therapeutic accuracy. The majority of US teaching medical institutions have incorporated them into clinical training. Many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries. We sought to determine the utility of EBCRs in an East African medical school.

SETTING

The University of Rwanda (UR), a medical school located in East Africa.

PARTICIPANTS

Medical students and faculty members at UR.

INTERVENTIONS

We offered medical students and faculty at UR free access to UpToDate, a leading EBCR and conducted a cohort study to assess its uptake and usage. Students completed two surveys on their study habits and gave us permission to access their activity on UpToDate and their grades.

RESULTS

Of the 980 medical students invited to enrol over 2 years, 547 did (56%). Of eligible final year students, 88% enrolled. At baseline, 92% of students reported ownership of an internet-capable device, and the majority indicated using free online resources frequently for medical education. Enrolled final year students viewed, on average, 1.24 topics per day and continued to use UpToDate frequently after graduation from medical school. Graduating class exam performance was better after introduction of UpToDate than in previous years.

CONCLUSIONS

Removal of the cost barrier was sufficient to generate high uptake of a leading EBCR by senior medical students and habituate them to continued usage after graduation.