الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Evidence based medicine defined as “conscientious, explicit, and judicious use of current
best evidence.” It involves integrating individual clinical expertise with the best available
external clinical evidence and compassionate use of individual patients’ rights and preferences in
making clinical decisions about their care. The traditional method of acquiring information has
been the review of traditional textbooks and ongoing review of medical journals. Unfortunately,
it has been shown that traditional texts go out of date quickly.
With the development of modern technology which allows easy and rapid access to
MEDLINE and other full-text rapid internet access sites, an increasing number of busy
practitioners have been able to obtain current evidence. When reviewing a volume of evidence on a
particular topic, it is important to understand there are different levels of evidence, i.e. not all forms of
evidence can be considered of equal value (Levels of evidence 1, 2, 3, 4).Also the GRADE system of
recommendation, applied explicit definitions of quality of evidence are given to increase the
degree of transparency and to be practical for clinicians. The system illustrates the four
categories of evidence (high, moderate, low, and very low) with their explanations.
Clinical practice guidelines (CPGs) are defined as “systematically developed statements to
assist practitioner and patient decisions about appropriate healthcare for specific clinical
circumstances.” They are tools used by healthcare professionals to assist in clinical decisionmaking
and to improve healthcare for patients. CPGs are to improve the quality of healthcare and
outcomes for patients. One simple definition of quality in healthcare is providing the right care,
at the right time, for the right person in the right way.
Clinical practice guidelines bridge the gap between policy and practice and should be based
on up-to-date, high quality research findings. Reducing the burden of disease in resource-poor
settings relies on the availability of such evidence-based clinical practice guidelines. However, as
with the original rope-and-stake guidelines, the use of evidence-based CPGs allows non-experts
the opportunity to care for their patients and clients in a manner similar to the best experts in the
field.
The potential benefits to health care professionals include improved quality of clinical
decisions in association with support for quality assurance activities and outcomes assessments.
Family physicians and other health care practitioners must be familiar with there is a real and
pressing need for guidelines in related fields of clinical practice to be integrated, harmonized
and, as is safely and scientifically possible, simplified.
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The Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument was developed
to address the issue of variability in the quality of practice guidelines. It is important to assess the
methods used to develop practice guidelines in order to be confident of the resulting
recommendations. The AGREE instrument is a tool that assesses the methodological rigour and
transparency in which a guideline is developed and it is used internationally.
The AGREE II is both valid and reliable and comprises 23 items organized into the original 6
quality domains: i) scope and purpose; ii) stakeholder involvement; iii) rigour of development;
iv) clarity of presentation; v) applicability; and vi) editorial independence. Each of the 23 items
targets various aspects of practice guideline quality. The AGREE II also includes 2 final overall
assessment items that requires the appraiser to make overall judgments of the practice guideline
and considering how they rated the 23 items.
The aim of the present study was to evaluate the Egyptian Practice Guidelines for Family
Physicians in Alexandria by:
1- Evaluating Egyptian clinical practice guidelines for Family Physicians by applying the
AGREE instrument.
2- Assessing Family Physicians’ knowledge and attitude about Egyptian Practice Guidelines for
Family Physicians and evidence based medicine.
3- Comparing between Egyptian clinical practice guidelines for management of hypertension and
diabetes mellitus and international guidelines (JNC 7) and (AACE)
To conduct the present study the following techniques were used:
I. The AGREE instrument for Guidelines evaluation was used for :
1. Evaluation of Egyptian Practice Guidelines for family physicians.
2. Comparison between Egyptian clinical practice Guidelines for management of
hypertension, diabetes mellitus and international guidelines for same diseases (JNC 7)
and (AACE).
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II. A self-administered questionnaire has been designed for family physicians to assess
their knowledge and attitude: A pilot study was conducted, which led to some
modifications and local adaptations
This questionnaire included six main sections:
a) The first section asked about General characteristics of family physicians and health facilities.
b) The second section measured family physicians, knowledge and attitude about EBM.
c) The third section asked about family physicians, opinion about barriers to practicing EBM.
d) The forth section asked about family physicians, awareness of various EBM resources.
e) The fifth section asked about family physicians, opinion about the methods to shift from
opinion based practice to EBM to practicing EBM.
f) The sixth section assessed family physicians, knowledge and attitude towards Egyptian
Clinical Practice Guidelines for family physicians.
Data were subjected to statistical analysis and interpretation.
The results of the present study could be summarized as follow:
1- Evaluation of Egyptian Clinical Practice Guidelines for Family Physicians applying the
AGREE instrument found only the ‘scope and purpose’ domain was reported most
comprehensively while the remaining five domains: (stakeholder involvement, rigour of
development, clarity and presentation, applicability and editorial independence domains)
were substantially low.
2- The total score of all six domains of AGREE II for these GLs (scope and purpose,
stakeholder involvement, rigour of development, editorial independence, clarity and
presentation and applicability domains) was 71 out of 161.
3- from the exciting assessment by AGREEII instrument it was found these GLs had a low
quality and scored 2 out of 7.
4- Regarding to assessment of Family Physicians’ knowledge and attitude about Egyptian
Practice Guidelines for Family Physicians and evidence based medicine. Majority of
physicians (81.6%) were females. Half of them (50.3%) had experience less than 10 years
in family practice. (30.0%) of the sample didn’t have any post graduate. (77.9) received
training courses in family medicine.
5- The physicians showed acceptable level of knowledge toward EBM and Egyptian clinical
practice GLs as more than half of the physicians (55.2%) had good level of knowledge.
However, (57.7%) of physicians had negative attitude toward EBM.
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6- Attending pervious training courses showed significant effect on knowledge score of
physicians as the majority of physicians with good level of knowledge (91.1%) received
training courses in family medicine and PHC. while the post graduate studies did not
have a significant effect on their level of knowledge except for those who had Egyptian
Fellowship Board.
7- The majority (84.6%) of family physicians sample welcomed the promotion of EBM;
(63.8%) of the physicians claimed that their colleagues welcomed the promotion of EBM.
Nearly three quarters (72.2%) of physicians agreed that EBM is useful in management of
patients, and (81.6%) of them believed that EBM guides their clinical decision making.
8- Also pervious training courses showed significant effect on total attitude score of
physicians as all physicians with positive attitude level have received training courses in
family medicine and PHC. However, post graduate studies did not have an effect on
attitude level of physicians.
9- The most commonly mentioned barrier to the practice of EBM was insufficient time
(64%). Followed by, Lack of investment by health authorities (46%).
10- It was found a statically significant relation between the year of graduation and
awareness of various EBM electronic information and internet resources. As awareness
increased with recently graduated physicians compared to older age graduates. Also most
of physicians had little awareness and utilization of varies electronic information
resources of EBM.
11- Surprisingly, about (22.7%) of family physicians didn’t have any idea about Egyptian
practice guidelines. Moreover, it was found that (57.7%) of physicians didn’t receive any
training courses about these guidelines. only (38%) of physicians found these guidelines
as a trustworthy.
12- Comparison between Egyptian clinical practice guidelines for management of
hypertension and diabetes mellitus and international guideline DM (AACE) and HIN
(JNC7) Applying the AGREE instrument. Only the ‘scope and purpose’ domain was
reported most comprehensively in Egyptian GLs. while the remaining five domains:
(stakeholder involvement, rigour of development, clarity and presentation, applicability
and editorial independence domains) were substantially low but a bit better than those
previously described in overall Egyptian GLs. While international guideline of DM
(AACE) and HIN (JNC7) was obtained maximum score with AGREE II tool.
13- from the exciting assessment by AGREE II instrument both Egyptian GLs in DM and
HIN were obtained low quality score as scored 2 out of 7. These results make them not
recommended for practice in overall assessment. While both DM (AACE) and HIN
(JNC7) GLs reported better scores in this evaluation and are recommend for practice use.
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According the following can be recommended:
1. Importance of acquiring EBM skills should be given to planning and executing EBM
education for family physicians while they are still in training.
2. Planning for the integration of teaching EBM skills in clinical practice.
3. Frequent evaluation of EBM knowledge, skills and attitudes Family physician should be
carried out.
4. Family physician straining to ensure correct application of EBM ideals in daily practice.
5. Family physicians should be doing more effort to learn the skills of critical appraisal and
evaluation of CPGs and EBM.
6. Identification of the weak areas in the existing guidelines could usefully be put in
consideration when producing future guidelines.
7. Guidelines should be reviewed by an independent body before publication.
8. Initiate collaboration with experts in the field of guideline development could support
capacity development and aids the process of bridging research and practice.
9. There may be value in creating a national guideline support committee, through this
committee, can assist all member states to adapt, maintain and update in-country
guidelines of high standard.
10. Given the time-intensive and resource-intensive nature of CPG development, local
adaptation of existing international high-quality CPGs to the national context might be a
more realistic approach to developing national or continental CPGs to avoid duplication
of efforts.