Izcovich Ariel, Criniti Juan Martín, Popoff Federico, Ragusa Martín Alberto, Gigler Cristel, Gonzalez Malla Carlos, Clavijo Manuela, Manzotti Matias, Diaz Martín, Catalano Hugo Norberto, Neumann Ignacio, Guyatt Gordon
Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina.
Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
BMJ Open. 2017 Aug 7;7(8):e016113. doi: 10.1136/bmjopen-2017-016113.
Using the best current evidence to inform clinical decisions remains a challenge for clinicians. Given the scarcity of trustworthy clinical practice guidelines providing recommendations to answer clinicians' daily questions, clinical decision support systems (ie, assistance in question identification and answering) emerge as an attractive alternative. The trustworthiness of the recommendations achieved by such systems is unknown.
To evaluate the trustworthiness of a question identification and answering system that delivers timely recommendations.
Cross-sectional study.
We compared the responses to 100 clinical questions related to inpatient management provided by two rapid response methods with 'Gold Standard' recommendations. One of the rapid methods was based on PubMed and the other on Epistemonikos database. We defined our 'Gold Standard' as trustworthy published evidence-based recommendations or, when unavailable, recommendations developed locally by a panel of six clinicians following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Recommendations provided by the rapid strategies were classified as potentially misleading or reasonable. We also determined if the potentially misleading recommendations could have been avoided with the appropriate implementation of searching and evidence summary tools.
We were able to answer all of the 100 questions with both rapid methods. Of the 200 recommendations obtained, 6.5% (95% CI 3% to 9.9%) were classified as potentially misleading and 93.5% (95% CI 90% to 96.9%) as reasonable. 6 of the 13 potentially misleading recommendations could have been avoided by the appropriate usage of the Epistemonikos matrix tool or by constructing summary of findings tables. No significant differences were observed between the evaluated rapid response methods.
A question answering service based on the GRADE approach proved feasible to implement and provided appropriate guidance for most identified questions. Our approach could help stakeholders in charge of managing resources and defining policies for patient care to improve evidence-based decision-making in an efficient and feasible manner.
运用当前最佳证据为临床决策提供依据，对临床医生而言仍是一项挑战。鉴于缺乏能为临床医生日常问题提供建议的可靠临床实践指南，临床决策支持系统（即协助问题识别与解答）成为颇具吸引力的替代方案。此类系统所提供建议的可信度尚不明晰。
评估一个能提供及时建议的问题识别与解答系统的可信度。
横断面研究。
我们将两种快速响应方法针对100个与住院患者管理相关的临床问题给出的回答，与“金标准”建议进行了比较。其中一种快速方法基于PubMed，另一种基于Epistemonikos数据库。我们将“金标准”定义为可信的已发表循证建议，若无法获取，则为由六位临床医生组成的小组按照推荐分级评估、制定与评价（GRADE）方法在本地制定的建议。快速策略提供的建议被归类为可能具有误导性或合理。我们还确定了通过适当运用检索和证据总结工具，是否可以避免可能具有误导性的建议。
两种快速方法均能回答所有100个问题。在获得的200条建议中，6.5%（95%可信区间3%至9.9%）被归类为可能具有误导性，93.5%（95%可信区间90%至96.9%）为合理。13条可能具有误导性的建议中，有6条可通过适当使用Epistemonikos矩阵工具或构建结果总结表来避免。在所评估的快速响应方法之间未观察到显著差异。
基于GRADE方法的问题解答服务经证明可行，可为大多数识别出的问题提供适当指导。我们的方法有助于负责管理资源和制定患者护理政策的利益相关者，以高效且可行的方式改善循证决策。
