Evidence Based Medicine- does local clinical research impact on local clinical management? a Preliminary investigation

BACKGROUND There is a large amount of variation in the degree to which practice guidelines and clinical research (evidence based medicine (EBM)) are used in daily patient management. Many attribute the variation to difficulty staying current with the volume of material published every year and a poor understanding of statistical analysis. Recent attention has been focused on EBM generated at specific institutions where the staff does not adopt the practice patterns supported by the EBM. Two randomized blinded trials comparing laparoscopic appendectomy (LA) to open appendectomy (OA) were completed at our institution in 1998 and 2006. Despite the outcome of these studies, the volume of laparoscopic procedures has increased dramatically.
METHODS The protocol design was reviewed and approved by the Institutional Ethics Committee. A retrospective review of appendectomies performed at our institution was conducted beginning in 1998 and ending in 2006. CPT codes were queried in an effort to determine surgical approach used (LA vs. OA). An anonymous interned based survey was distributed to all members of the Department of Surgery, to include those who participated in the above mentioned trials. Questions included preferred surgical approach in children, males, females, and obese adults. Questions also addressed perceptions regarding the quality of the clinical trials performed at our institution as well as knowledge of the results of the same trials.
RESULTS 12% of the appendectomies performed in 1998 were LA, by 2006, over 70% were LA. Of the responders, over 50% were board certified and 37% were subspecialty trained. The majority of surgeons reviewed were comfortable with either approach (OA or LA) and all felt that there was sufficient volume to maintain their surgical skills. Most preferred the LA approach citing various reasons including better visualization of the pelvic structures and surgeon comfort. The majority (79%) were aware of the locally produced EBM which did not support LA as the procedure of choice.
CONCLUSIONS Despite a high degree of comfort with either procedure, and locally generated EBM regarding the lack of clinical superiority and economic inferiority of the LA, this is still the preferred treatment for patients with acute appendicitis by our surgeons for a variety of reasons which are not supported by the EBM.

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Program Number: P178

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