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SYSTEMATIC REVIEW

Barriers to evidence-based medicine: a systematic review Homayoun Sadeghi-Bazargani PhD,1 Jafar Sadegh Tabrizi PhD2 and Saber Azami-Aghdash PhD3,4

1Professor, PhD of Epimiology, Road Traffic Injury Prevention Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 2Professor, PhD of Health Service Management, 3PhD Student, Tabriz Health Services Management Research Center, Department of Health Service Management, Tabriz University of Medical Sciences, Tabriz, Iran 4PhD Student of Health Policy, Hospital Management Research Center, Iran University of Medical Sciences, Tehran, Iran

Keywords barrier, content analysis, evidence-based medicine, guideline, research utilization, systematic review

Correspondence Dr Saber Azami-Aghdash Hospital Management Research Center Iran University of Medical Sciences Tehran, 59771-45556 Iran E-mail: [email protected]

Accepted for publication: 30 May 2014

doi:10.1111/jep.12222

Abstract Introduction Evidence-based medicine (EBM) has emerged as an effective strategy to improve health care quality. The aim of this study was to systematically review and carry out an analysis on the barriers to EBM. Methods Different database searching methods and also manual search were employed in this study using the search words (‘evidence-based’ or ‘evidence-based medicine’ or ‘evidence-based practice’ or ‘evidence-based guidelines’ or ‘research utilization’) and (barrier* or challenge or hinder) in the following databases: PubMed, Scopus, Web of Knowledge, Cochrane library, Pro Quest, Magiran, SID. Results Out of 2592 articles, 106 articles were finally identified for study. Research barriers, lack of resources, lack of time, inadequate skills, and inadequate access, lack of knowledge and financial barriers were found to be the most common barriers to EBM. Examples of these barriers were found in primary care, hospital/specialist care, rehabili- tation care, medical education, management and decision making. The most common barriers to research utilization were research barriers, cooperation barriers and changing barriers. Lack of resources was the most common barrier to implementation of guidelines. Conclusion The result of this study shows that there are many barriers to the implemen- tation and use of EBM. Identifying barriers is just the first step to removing barriers to the use of EBM. Extra resources will be needed if these barriers are to be tackled.

Introduction The main reason for different performance in health care is the gap between knowledge production and its implications. To eliminate this gap, in recent years, the evidence-based practice (EBP) approach has been considered [1–3]. EBP has emerged as a inter- national priority in efforts to improve health care quality [4] and defined as the integration of clinical experience with high quality evidence and patients’ values [5,6]. EBP is achieved by translating the need for information into an answerable clinical question, then tracing the most valid information, critically appraising and finally making use of it in a clinical setting [7].

Unfortunately, despite the positive role of EBP in health care quality and the improvement in patient care [8,9], the evidence clearly shows that there are many barriers in both the use of evidence and the implementation of EBP. The major barriers included lack of time, lack of knowledge, lack of medical resources, negative attitudes about EBP, financial constraints, etc. [2,10–13].

EBP has been introduced at many levels and in many fields of health care systems, such as primary health care [14,15], second- ary and specialist care (hospitals) [16,17], rehabilitation care [18,19], medical education [20], management and decision making [21] and other fields. Many studies have been conducted to identify the barriers to EBP in recent years. There is however not one comprehensive study that combines the results of these studies and provides a clear view of the barriers. Therefore, the primary aim of this study was to systematically review and carry out content analysis to determine barriers to EBP in Primary Health Care (PHC), secondary and specialist care (hospitals), rehabilita- tion care, medical education, management and decision making, implementation of guidelines, use of research results.

Methods and materials In the systematic review to find relevant studies, a search strategy was developed with the cooperation of an experienced librarian. The search strategy was conducted first on PubMed, than adjusted

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to search other databases (Supporting Information Appendix S1). The keywords was selected from MeSH and included evidence- based*, ‘evidence-based medicine’, ‘evidence-based practice’, ‘evidence-based guidelines’, ‘research utilization’, barrier*, chal- lenge, hinder. These were used in PubMed, Scopus, Cochrane library, Web of knowledge, Pro Quest, Magiran (Persian database) and SID (scientific information database – Persian database) data- bases. Manual journal searching (such as evidence-based medi- cine, evidence-based mental health, evidence-based nursing, medical decision making, evidence-based complementary and alternative medicine, evidence-based ophthalmology, Interna- tional Journal of Evidence-Based Healthcare and etc.) was also conducted. Articles from the reference list of the studies and which were found to be relevant were also considered. The literature search was conducted from January 2000 to September 2013.

Articles in English and Farsi (Persian) were included that reported barriers to EBP in PHC, secondary and specialist care (hospitals), rehabilitation care, medical education, management and decision making, implementation of guidelines, use of research results. The exclusion criteria were letters to the editor, case reports, papers presented in seminars and conferences and articles, which resulted from interventions.

Two reviewers evaluated the articles according to the checklist from STROBE (Strengthening the Reporting of Observational studies in Epidemiology for observational studies [22], Critical Appraisal Skills Program (CASP) for qualitative study [23] and Preferred Reporting Items for Systematic reviews and Meta- Analyses (PRISMA) for systematic review studies [24]. First, arti- cles with non-relevant titles to the subject of this review were excluded. Then, the abstract and the full text of articles were reviewed respectively to exclude those articles that matched the exclusion criteria of the study, or had a weak relevance to the subject of the study. A computer software for reference manage- ment (Endnote X5, Thomson Reuters, Philadelphia, PA 19130, USA) was used for organizing and assessing the titles and abstracts, as well as recognizing the repetitive items.

Deductive content analysis was carried out to categorize and understand the barriers and facilitators related to EBP. Coding and categorizing was done by two people from the research team using the following process:

1 Familiarization with data (identifying and extracting barriers from selected studies); 2 Searching for themes (gathering extracted barriers and facilita- tors into potential themes); 3 Formulating themes (generating a thematic ‘map’); 4 Naming themes (generating clear definitions/examples for themes), and 5 Assessing reliability of analysis by use of two researchers trying to achieve full agreement.

The searches returned 2592 articles, and excluding those that were non-relevant, repetitive between databases, with weak rel- evance to the study, or matching the exclusion criteria, 106 articles were entered in the study (Fig. 1). These articles were fully read, and the required data were extracted into the extraction table designed for the purpose of the study in spreadsheet computer software (Excel, Microsoft Office, Microsoft, USA).

Results In this study, out of 2592 articles, 106 articles completely related to the study aims were finally selected, carefully studied and the relevant data extracted into the extraction table (Supporting Information Appendix S2).

The frequency of each area of study is following: primary care 15(%14.1), hospital/specialist care 29(27.6%), rehabilitation care 14(%13.3), Medical education 6(5.7%), management and decision making 4(3.8%), Guideline implementation 16(15.2%), Research utilization 8(7.2%) and General (all above mentioned) 14(13.3%).

In this study, 1144 barriers were identified and using content analysis categorized into 18 categories (Fig. 2).

As can be seen in Fig. 2, the most common barriers were related to ‘research barrier’ by 126 frequencies.

In Table 1, for greater clarification of the categorizing of barri- ers, some examples are given for each category.

In Table 2, the first five most common barriers in primary care, hospital/specialist care, rehabilitation care, medical education and management and decision making were compared.

As can be seen in Table 2, lack of resources, lack of time, research barriers and lack of knowledge are the most common

Excluded at full text = 276

Inadequate results: 204

Poor quality of article in assessing: 72

Full text selected = 371

Total included article = 106

Relevant article identified = 2592

Excluded at duplicate between database = 856

Excluded at Title and abstract = 1365

Non relevant = 989 Presented at conferences and seminars = 189 Letter to the editors = 78 Case reports = 50 Interventional study = 59

Included at hand searching and references of references =11

Titles and abstract for screening = 1736

Figure 1 Flow diagram of the searches and inclusion process.

Barriers to EBM H. Sadeghi-Bazargani et al.

barriers respectively in primary care, hospital/specialist care, reha- bilitation care, medical education and management and decision making.

The most common barriers to RU are shown in Fig. 3. As can be seen in Fig. 3, barriers related to research with 52

repeated was the most common barriers to research utilization (RU) in the health care system.

Most common barriers to guideline implementation in the health care system are shown in Fig. 4.

As can be seen in Fig. 4, lack of resources was the most common barrier to implementation of guidelines.

Discussion The summary and analysis of the study results show that research barriers, lack of resources, lack of time, inadequate skills, and inadequate access, lack of knowledge and financial barriers are the most common barriers to the implementation and use of EBP. Examples of these barriers are to be found in primary care, hospital/specialist care, rehabilitation care, medical education, management and decision making. So that lack of resources, lack of time, research barriers and lack of knowledge are respectively the most common barriers in this area. The most common barriers to RU in the health care system were research barriers, cooperation barriers and changing barriers. Lacks of resources were the most

common barriers to implementation of guidelines. In this study, for 18 categories of barriers, 37 facilitators were suggested.

In consistence with some of previous studies [10,19,25–28], the results of this study show that barriers related to ‘research’ are one of the most common barriers to the implementation and use of EBP. We can categorize these barriers into three main categories namely (1) heterogeneity in distribution of studies (high volume in some areas and inadequate studies in other areas); (2) methodological problems in study design and execu- tion and (3) conducting of studies that were not applicable and usable (such as duplicate or unnecessary studies). Many inter- ventions could be done to improve these problems, such as conducting educational workshops or courses for health care pro- viders to improve their ability and knowledge in the designing and conducting of studies, comprehensive and clear reporting of research results, using rigorous criteria and standards for publi- cation of studies, conducting research according to the user’s needs, collecting the study’s results in one place and providing access for health care providers.

In this study, another important barrier to EBP was ‘lack of resources’ such as inadequate facilities, institutional support and lack of equipment. Results of previous studies also show that lack of resources is one of the most serious barriers to the implemen- tation and use of EBP [29–34]. To solve this problem, in the first phase, we would try to provide adequate resources. If this is not

0 10 20 30 40 50 60

Researech barrier

Changing barrier

Cooperate barrier

Lack of knowledge

Lack of time

External factors

Negative attitude

Inadequate access

Languge barriers

Lack of source

Inadequate skill

No incentive

Lack of training

Financial barrier

Not priority

Logistical barrier

Frequency

Barriers

Figure 2 The most common barriers to EBP at health care system level (n = 1140).

H. Sadeghi-Bazargani et al. Barriers to EBM

possible, in the next phase, we would use low-cost strategies for the implementation and use of EBP. Unfortunately, sometimes there are adequate resources but we cannot use them appropriately. Because there is not appropriate planning we are unable to do proper resource allocation.

The results of this study are in agreement with previous study results [16,18,35–44] and show that barriers related to ‘lack of time’ are one of the most common kinds in EBP. We can categorize these barriers into two main categories: (1) lack of time to search for, study and learn from studies, and (2) lack of time in the implemen- tation of study results in the job setting. One of the probable reasons for lack of time is health care providers’ high workload. To solve this problem, it is proposed that the staff workload is reduced or that more staff is employed. Another likely reason for the lack of time

may be the staff’s lack of ability in time management. To solve this problem, running ‘time management’ workshops can be useful.

According to the results of this study, the pattern of barriers in primary care, hospital/specialist care, rehabilitation care, medical education, management and decision making, implementation and use of guidelines and research utilization are deficient. Therefore, it is considered necessary that policymakers and managers con- sider this issue when decision making and planning.

Among the deficient areas in this study, management and deci- sion making have the lowest frequency of studies. Due to the importance of evidence-based management and decision making, more study needs to be carried out in this area.

Out of 106 studies that are surveyed in this study, a few of them were conducted in Low and Middle Income countries (LMIC). In

Table 1 Examples for most common barriers

Barriers Examples

Research barrier Conflicting results, methodological problems, lack of replication, poor generalizability, understanding statistics, literature not being compiled in one place, implications for practice not being made clear, limited relevance of research to practice

Lack of resources Inadequate facilities, lack of medical resources, inadequate institutional support, lack of equipment Lack of time Lack of time to search for guidelines or practice EBD, lack of time to study, no time to search for information, insufficient

time on the job to implement new ideas, no overtime or comp time for after-hours appointments Inadequate skills Lack of research skills, lack of skills to effectively communicate, inability to evaluate Inadequate access Guidelines are not accessible, guidelines are too complicated and it is difficult to find the information, distance from the

library, Lack of knowledge Do not know how to search, lack of self-learning skills, lack of exposure to evidence-based interventions, lack of awareness

of interventions, ignorance of the research relevant to clinical practice areas, lack of capability to evaluate the quality of the research

Financial barriers Lack of infrastructure, EBP is too costly, funding shortage/limited, the costs of patient choice, the costs of consumerism, the costs of accessing evidence

Lack of training Insufficient/inappropriate EBD training in dental school, inadequate continuing education in EBD Cooperate barriers Lack of teamwork, being isolated from colleagues, doctors not cooperating with change, doctors unwilling to cooperate

with nurses’ implementation of EBP Negative attitude Negative attitudes about EBP, guidelines reduce doctors’ autonomy, guidelines limit treatment options, guidelines limit

flexibility and individual approach, there is no need for treatment guidelines as treatment routines exist No incentive Lack of motivation to update knowledge, no motivation from trainer unsupported Inadequate supervision and leadership, Changing barriers Difficulty in changing current practice model, willingness to change, lack of autonomy, lack of authority, insufficient

resources to change practice Not priority Low management priority, lack of agreed priorities Patient barriers Consumer demand, client resistance/non-participation/disengagement, clients difficult to reach/follow-up/track Logistical barrier No clear structures or process, loss of therapeutic freedom Language barriers Language barrier, written in English External factors Negative sociocultural beliefs, difficulty in application with national health insurance

Table 2 Five most common barriers in primary care, hospital/specialist care, rehabilitation care, medical education, management and decision making

Field priority Primary care Hospital/specialist care Rehabilitation care Medical education

Management and decision making

1 Lack of source Lack of time Research barrier Research barrier Lack of knowledge 2 Inadequate skills Research barrier Lack of source Lack of time Lack of time 3 Lack of training Lack of source Lack of time Lack of knowledge Research barrier 4 Lack of time Inadequate skills Inadequate access Lack of training –* 5 Not priority Cooperate barriers Lack of training Unsupported –

*There is not enough study in this field

Barriers to EBM H. Sadeghi-Bazargani et al.

agreement with this result, Agarwal and colleagues (2008) [45] emphasized that South Asian countries have weak performance in the field of EBM and there are many barriers in these countries. Lack of resources, inadequate skills, lack of knowledge and finan- cial barriers are some of the most common barriers. To deal with

these barriers, educational programmes to improve staff’s ability and knowledge, strategic planning for implementation and use of EBP, use of high-income countries’ experience, following local health guidelines, modifying and removing legislation barriers and other effective interventions can be used.

Figure 3 The most common barriers to RU in health care system (n = 152).

Figure 4 The most common barriers to guideline implementation in health care system (n = 155).

H. Sadeghi-Bazargani et al. Barriers to EBM

The main weakness of this study is the combination of the results of quantitative studies with qualitative studies. Therefore, it is recommended that in future studies, results of these different kinds of studies are reported separately. The other limitation of this study was being limited in the searches to only English and Persian because of the researchers only knowing these two languages.

Conclusion Nowadays, due to rapid growth in the volume of medical informa- tion and complex treatment procedures, we need to use the best and most valid evidence. But a review of studies shows that there are many barriers to achieving this goal. Barriers related to ‘research’, ‘lack of source’ and ‘lack of time’ are most common. Therefore, a priority for future effective interventions could be activities such as holding research methodology educational work- shops or courses, using rigorous criteria and standards for publi- cation of articles, providing extra resources for the collection and use of evidence, resource allocation and holding ‘time manage- ment’ workshops.

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