Bringing Evidence to the Bedside in Critical Care Allan S. Detsky Physician-in-Chief Mount Sinai Hospital

We need information If asked: We need it twice a week We get it from textbooks, journals and our colleagues

We really need information If shadowed: We need it twice for every 3 outpatients and 5 times for every patient But we rarely get what we need from the resources that we use – Colleagues –Textbooks –Journals Ann Intern Med 1991;114:576-81

Evidence of Care Gaps Beta blockers in post MI patients Statins in post MI patients ACE-I in patients with CHF Antithrombotic therapy in patients with nonvalvular atrial fibrillation

HOW CAN WE BRIDGE THIS GAP?

Bringing evidence to the point of care Need it within seconds if it is to be incorporated into busy clinical rounds Focus on users’ needs and important clinical outcomes Our initial attempts to bring the best evidence to a busy clinical team caring for over 200 patients per month JAMA 1998;280:

Kinds of Questions 1. Therapeutic Effectiveness 2. Diagnostic Accuracy 3. Prognostic Information

Therapeutic Effectiveness For patients with health state X, does Rx A do more good than harm (compared to Rx B)?

Diagnostic Accuracy Does test A help us separate those with disease from those without for patients that look like X?

Prognostic Information For patients with health state X, was the risk of an adverse outcome over a specified period of time?

What do clinicians want on PDAs? Clinical bottom line from preappraised resources Management algorithms Drug dosages and interactions Numerical summaries of risks and benefits They don’t want traditional clinical practice guidelines

Examples Computerized decision support systems (CDSS) Systems Synopsis Syntheses Studies Clinical Evidence Cochrane Reviews Original published articles in journals

Internet Available Resources

How To design 1. Learn how to recognize questions. 2. Learn how to quantify answers.

Therapeutic Effectiveness P c = event rate in control group P t = event rate in experimental group

P c - P t = ARD (P c - P t )/P c = PRD P t /P c = RR 1 = NNT P c - P t

10% - 5% = 5% = ARD (10% - 5%)/10% = 50% = RRD 5%/10% =.5 = RR 1 10% - 5% = 20 = NNT

DIAGNOSTIC TESTS Sensitivity Specificity Likelihood ratios

LR > 1 LR = 1 LR < 1

Read and appraise individual studies, systematic reviews

Then go to websites to see how results are presented.

Next - start a simple research project.

Medical Consults What is the validity of a cardiac risk index in our patients?

Start slowly Progress will take time It’s harder than you think