Michaud G, McGowan J L, van der Jagt R, Wells G, Tugwell P
Department of Internal Medicine, Ottawa General Hospital/University of Ottawa, Ontario, Canada.
Arch Intern Med. 1998;158(15):1665-8. doi: 10.1001/archinte.158.15.1665.
One of the most common decisions physicians face is deciding which therapeutic intervention is the most appropriate for their patients. In recent years much emphasis has been placed on making clinical decisions that are based on evidence from the medical literature. Despite the emphasis on incorporation of evidence-based medicine into the undergraduate curriculum and postgraduate medical training programs, there has been controversy regarding the proportion of interventions that are supported by health care research.
To investigate the proportion of major therapeutic interventions at our institution that are justified by published evidence.
One hundred fifty charts from the internal medicine department were reviewed retrospectively. The main diagnosis, therapy provided, and patient profile were identified and a literature search using MEDLINE was performed. A standardized search strategy was developed with high sensitivity and specificity for identifying publication quality. The level of evidence to support each clinical decision was ranked according to a predetermined classification. In this system there were 6 distinct levels, which are explained in the study.
Of the decisions studied, 20.9% could be supported by placebo-controlled randomized trials and 43.9% by head-to-head trials. Half of these were shown to be significantly superior to the treatment against which it was being compared. For 10 of the 150 clinical decisions, evidence was found demonstrating alternative therapies as being more effective than that selected.
Most primary therapeutic clinical decisions in 3 general medicine services are supported by evidence from randomized controlled trials. This should be reassuring to those who are concerned about the extent to which clinical medicine is based on empirical evidence. This finding has potential for quality assurance, as exemplified by the discovery that a literature search could have potentially improved these decisions in some cases.
医生面临的最常见决策之一是确定哪种治疗干预措施最适合他们的患者。近年来，人们非常强调基于医学文献证据做出临床决策。尽管强调将循证医学纳入本科课程和毕业后医学培训项目，但关于医疗保健研究支持的干预措施比例仍存在争议。
调查我院主要治疗干预措施中有多少有已发表证据支持。
回顾性审查了内科的150份病历。确定了主要诊断、提供的治疗方法和患者概况，并使用MEDLINE进行了文献检索。制定了一种标准化检索策略，用于识别高质量出版物，具有高灵敏度和特异性。根据预先确定的分类对支持每个临床决策的证据水平进行排名。在该系统中有6个不同的级别，本研究中对此进行了解释。
在所研究的决策中，20.9%可由安慰剂对照随机试验支持，43.9%可由直接比较试验支持。其中一半被证明明显优于与之比较的治疗方法。在150个临床决策中的10个中，发现有证据表明替代疗法比所选疗法更有效。
3个普通内科服务中的大多数主要治疗临床决策都有随机对照试验的证据支持。这应该会让那些担心临床医学基于经验证据程度的人感到安心。这一发现具有质量保证的潜力，例如发现文献检索在某些情况下可能会改善这些决策。
