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Promoting Evidence-based Practice in the Former Soviet Union and Central and Eastern Europe
By Mark Storey, Program Officer
Irina Carnevale, Information and Communication Technology Associate
American International Health Alliance
In the remote town of Schuche, nestled behind the Ural Mountains of Russia, most physicians have had limited access to current medical literature. In part as a result of this isolation, health institutions have largely been dependent on the often outdated protocols provided by the health ministry to guide them in the practice of medicine. In one local hospital, however, health professionals have found a way to update their practices using the best available research evidence with the help of the Internet.
At Schuche Central District Hospital, a group of gynecologists, concerned about growing numbers of undiagnosed and untreated cases of vaginal infections (which often lead to complications during pregnancy) decided to search the Internet for up-to-date information on diagnostic techniques. Noting that hospital staff have been following regulations and methods that had not been reviewed or evaluated since the Soviet period, they established a task force to conduct a literature search using MEDLINE and other on-line medical databases. After conducting the search, task force members assessed the quality of their findings to determine whether the research was valid and applicable to their conditions. Based on their assessment, the task force launched a successful campaign to convince and educate the hospital administration and staff about the advantages of using more effective (and less expensive) diagnostic methods. As a result, staff at the hospital are now using the Gram stain method for diagnosing bacterial vaginosis, and more patients are being diagnosed early and treated for this condition.
While conducting its assessment, the task force followed a process based upon the principles of evidence-based practice (EBP), an approach which provides a set of criteria for objective evaluation of health care information and aims to ensure effective integration of research evidence with practice. The EBP approach provides a five-step framework, which includes:
- Formulating a clinically answerable question,
- Finding the appropriate research evidence through a literature search,
- Critically appraising the literature,
- Applying the evidence to practice, and
- Evaluating the effectiveness of practice.
The Schuche hospital's example of EBP in action demonstrates the types of changes that are taking place at a number of health care institutions throughout the countries of the former Soviet Union and Central and Eastern Europe with the support of the American International Health Alliance (AIHA) Healthcare Partnerships Program. Through this program, AIHA, under a cooperative agreement with the U.S. Agency for International Development (USAID), creates partnerships between U.S. health care providers and their counterparts in the New Independent States of the former Soviet Union (NIS) and Central and Eastern Europe (CEE) to foster capacity-building programs that address the critical health problems they are facing. As part of the partnership model, AIHA coordinates a project to promote the adoption of evidence-based practice through the establishment of Learning Resource Centers (LRCs) at each of its overseas partner institutions. By providing health professionals with access to the Internet and on-line medical databases and by training staff on the principles and methodologies of EBP, these LRCs have been able to support local health professionals in their efforts to improve health care delivery and quality.
Located at various healthcare institutions - hospitals, polyclinics, medical universities, research institutes and health care administration offices, LRCs have been able to facilitate evidence-based practice changes at the institutional as well as regional and national levels. At the institutional level, many patient care facilities are now using the latest research to validate and update diagnostic and treatment methods. Some of these have begun to tap into EBP as a mechanism for revolutionizing the interaction between physicians and patients. For example, physicians in the rheumatology department at a large hospital in Vladivostok, Russia, have developed and implemented a form for patients called a "protocol of informed consent." This document, adapted to individual diagnoses, explains disease etiology, treatment goals, and the responsibilities of both the physician and the patient, and then lists a variety of treatment options and their associated costs. Together, the patient and the physician decide on the course of treatment, sign the document and keep a copy for their records. True to EBP ideals, this approach integrates the best research evidence with physicians' clinical expertise and patient values. By fully informing patients about the range of treatment options, providing them with the latest evidence about likely effectiveness, and adapting treatment to individual choices and economic circumstances, the traditionally authoritarian physician/patient relationship is transformed into a partnership. Over the course of several years, this innovative process has created better informed patients who feel empowered by their health care system. Moreover, this approach has led to health improvements for many rheumatology patients in Vladivostok.
At the regional and national levels, LRCs have been supporting the development of new health policies based, in part, on comparative experiences in other countries. They have also supported the introduction of clinical practice guidelines and revisions in medical school curricula. For example, the Department of Epidemiology at the Mechnikov Medical Academy in St. Petersburg, Russia, has developed and helped to implement guidelines on rational perioperative antibiotic prophylaxis, hand cleaning procedures, endoscopic equipment sterilization, and healthcare worker biosafety for several partner hospitals throughout the country. The new procedures have led to a decrease in hospital-acquired infections and staff injury and infection rates as well as helped hospitals to reduce costs. LRCs have also used evidence-based practice resources and methodologies to create national-level emergency medicine guidelines in Uzbekistan and to initiate health care system reforms in collaboration with the Ministry of Health of Slovakia.
Through the LRCs, AIHA has tried to instill the philosophy and principles of EBP among health professionals at all of its partner institutions. One tool AIHA has developed in order to help LRC staff to provide their colleagues with a deeper, practical understanding of this philosophy is the "Practice Standard Review." This instrument helps health professionals, preferably working in discussion groups, to go through the first four steps of the EBP methodology and compare the research evidence to existing practice.
After going through this exercise, many health practitioners come to the realization that their common assumptions about diagnosis, treatment and prevention may not always be supported by the latest research and that they can improve their effectiveness by periodically reviewing the relevant medical literature. In many cases, this process has led to the introduction of new practices and procedures that are evidence-based - and more cost-effective for the under-funded health care institutions in the region. With support from over 130 LRCs in 22 countries, practicing physicians, nurses, educators, hospital managers, researchers and policymakers in the region are slowly bringing about positive changes at all levels of the health care system.
American International Health Alliance
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