The impact of evidence on physicians’ inpatient treatment decisions

Abstract

OBJECTIVE:Previous studies have shown that most medical inpatients receive treatment supported by strong evidence (evidence-based treatment), but they have not assessed whether and how physicians actually use evidence when making their treatment decisions. We investigated whether physicians would change inpatient treatment if presented with the results of a literature search.DESIGN: Before-after study. SETTING: Large public teaching hospital.PARTICIPANTS: Random sample of 146 inpatients cared for by 33 internal medicine attending physicians. INTERVENTIONS:After physicians committed to a specific diagnosis and treatment plan, investigators performed standardized literature searches and provided the search results to the attending physicians. MEASUREMENTS AND MAIN RESULTS:The primary study outcome was the number of patients whose attending physicians would change treatment due to the literature searches. However, to conclude from these studies that most medical inpatients receive evidence-based treatment is potentially misleading.9,10 None of the studies assessed whether or how physicians actually used evidence when making their treatment decisions. Nor did they determine whether, as a result, patients received the best available treatment. (For particular patients, some evidence-based treatments are better than others.) All of these considerations -physicians' judgments, patients' unique clinical circumstances, and the evidence relevant to various treatment options -are essential to the practice of evidencebased medicine. 11In order to explore these important issues further, we sought to measure the potential efficacy of actually practicing evidence-based medicine. In the present study, we assessed the impact of standardized literature searches on attending physicians' treatment decisions for medical inpatients. METHODS Study DesignWe performed a before-after study of physicians' treatment decisions for a random sample of patients admitted to a general medicine inpatient service at one hospital. Before performing a standardized literature search, we elicited from the attending physician the patient's primary clinical problem (the principal diagnosis requiring inpatient treatment) and the specific treatment being given for it. After searching the medical literature about the patient's problem, we presented the search findings to the attending physician and asked whether he or she would change the patient's treatment as a result of the literature search. Figure 1 outlines the study design within the conceptual framework of therapeutic decision making. This model assumes that physicians typically consider various treatment options before committing to a specific treatment. We hypothesized that a literature search would cause physicians to change their treatments if the search identified treatment options not previously considered or provided data that altered their evaluation of treatment options.

Impact of a bedside procedure service on general medicine inpatients: A firm‐based trial

“…Our findings suggest that although patients' clinical circumstances are likely the most important consideration, nonclinical factors may also affect physicians' decisions. 12 Like other multifaceted decision-making processes of physicians, 15 the complexity of this decision is important to examine because, as our pilot data suggest, a procedure service may not lead to more successful procedure attempts or reductions in the number of major complications. Although the cumulative expertise of our service or the innovative methods of training of other institutions may improve the performance of bedside procedures, 5,13 physicians' decisions about whether to order them will remain paramount, because any improvement in procedural competence will do little to reduce the relative danger of unnecessary procedures 16 or the missed benefit of procedures left undone.…”

Enhancing evidence-based advice of occupational health physicians

“…However, several studies in occupational health have shown that there is ample room for improvement in the quality of care, and they give clear indications that the use of available evidence in the scientific literature or evidence-based guidelines could be an important vehicle for this purpose (5)(6)(7)(8). While the application of evidence in the decision-making process of occupational health physicians is still not routine in daily practice, the potential impact of the use of evidence in the decision-making process of clinical physicians has already been illustrated by several studies showing up to 60% improved decisions if evidence was searched for or provided (9)(10)(11). Therefore, in this study, we strived to stimulate the implementation of evidencebased medicine in occupational health to enhance further the professional performance of occupational health physicians and improve occupational health care.…”

Use of UpToDate and outcomes in US hospitals

“…UpToDate has previously shown to help providers answer questions rapidly, which can lead to changes in decision-making that can improve management and efficiency. 1,7,14 Ours is the first national study, to our knowledge, that has directly examined the relationship between UpToDate and key outcome metrics. Bonis et al have previously examined the use of UpToDate and its relationship to risk-adjusted LOS and mortality in a limited set of hospitals using a proprietary risk-adjustment scheme.…”

“…1,2,5,6 Previous studies of UpToDate and similar systems demonstrated that these systems improve acquisition of knowledge, increase the number of answered clinical questions, and change management decisions. 7,8 However, whether these changes lead to real improvements in clinical outcomes is unknown. Given the urgent need to improve both the quality and efficiency of healthcare, understanding whether UpToDate has the potential to improve outcomes is critical.…”