With its state-of-the-art, often futuristic technologies, intensive care has long been touted as an example of ‘c21st century’ medicine. Yet, as we now enter that century, intensive care arguably finds itself with a reputation somewhat tarnished. For example, the pulmonary artery catheter, a mainstay in the management of the critically ill, has been recently associated with harm to intensive care unit (ICU) patients [1], Similarly, emerging data regarding mechanical ventilation practice suggests that for years we may have been harming our patients with excessive tidal volumes and ventilatory pressures [2], [3]. And although we have made considerable in-roads in our understanding of the pathophysiology of sepsis and multiple systems organ failure, our field is littered with potential therapies that failed to improve outcomes in clinical trials.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsPreview
Unable to display preview. Download preview PDF.
References
Connors AFJ, Speroff T, Dawson N V, et al (1996) The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 276:889–897
Amato MB, Barbas C S, Medeiros D M, et al (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347–354
The NIH/NHLBI ARDS Network (1999) Low tidal ventilation is routinely used in patients with early acute lung injury. Am J Respir Crit Care Med 159:A694–A694 (Abst)
Pronovost P, Angus D C (1999) Determining the value of critical care. Clin Pulm Med 6:302–308
SUPPORT Principal Investigators (1995) A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments. JAMA 274:1591–1598
Kahn CR (1994) Picking a research problem. The critical decision. N Engl J Med 330:1530–1533
Hebert PC, Wells G, Blajchman M A, et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–417
Piantadosi S (1997) Clinical trials: A methodological perspective. John Wiley and Sons, New York
Sackett DL (1979) Bias in analytic research. J Chronic Dis 32:51–63
Pronovost PJ, Jencks M, Dorman T et al (1999) Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 281:1310–1312
Rubenfeld GD, Angus DC, Pinsky MR, et al (1999) Outcomes research in critical care: Results of the American Thoracic Society Critical Care Assembly Workshop on outcomes research. Am J Respir Crit Care Med 160:358–367
Cook DJ, Fuller HD, Guyatt GH, et al (1994) Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 330:377–381
Bone RC, Balk R A, Cerra F B, et al (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:1644–1655
Angus DC, Kramer DJ (1993) Bacteremia and sepsis: Clinical perspectives. In: Pinsky MR, Dhainaut JF (eds) Pathophysiologic Foundations of Critical Care Medicine. Williams and Wilkins, Baltimore, pp 96–111
Bernard GR, Artigas A, Brigham KL, et al (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824
Knaus WA, Sun X, Nystrom O, Wagner DP (1992) Evaluation of definitions for sepsis. Chest 101:1656–1662
Rubenfeld GD, Doyle RL, Matthay MA (1995) Evaluation of definitions of ARDS. Am J Respir Crit Care Med 151:1270–1271
Knaus WA, Harrell FE J, Fisher CJ, et al (1993) The clinical evaluation of new drugs for sepsis. A prospective study design based on survival analysis. JAMA 270:1233–1241
Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ (1995) Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 23:1638–1652
Vincent JL, Moreno R, Takala J, et al (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 22:707–710
Piper RD, Cook DJ, Bone RC, Sibbald WJ (1996) Introducing critical appraisal to studies of animal models investigating novel therapies in sepsis. Crit Care Med 24:2059–2070
Vincent JL (1997) Dear SIRS, I’m sorry to say that I don’t like you. Crit Care Med 25:372–374
Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP (1995) The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA 273:117–123
Salvo I, de Cian W, Musicco M, et al (1995) The Italian SEPSIS study: preliminary results on the incidence and evolution of SIRS, sepsis, severe sepsis and septic shock. Intensive Care Med 21:S244–S249
Sands KE, Bates DW, Lanken PN, et al (1997) Epidemiology of sepsis syndrome in 8 academic medical centers. Academic Medical Center Consortium Sepsis Project Working Group. JAMA 278:234–240
Dougnac A, Angus DC, Hernandez G, et al (1996) Severe SIRS in Chile: Natural history and new organ dysfunction scores. Intensive Care Med 22 (suppl 3):321 (Abst)
Angus, D. C, Dougnac, A., Hernandez, et al (1996) Sepsis and SIRS: Are we any nearer to consensus? Intensive Care Med 22 (suppl 3):273 (Abst)
Bone RC, Grodzin CJ, Balk RA (1997) Sepsis: a new hypothesis for pathogenesis of the disease process. Chest 112:235–243
Angus DC (1998) Discourse on method: Measuring the value of new therapies in intensive care. In: Vincent JL (ed), Yearbook of Intensive Care and Emergency Medicine, Springer-Verlag, Berlin, pp 263–279
Anonymous (1997) A comparison of reteplase with alteplase for acute myocardial infarction. The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO III) Investigators. N Engl J Med 337:1118–1123
Ware JH, Antman EM (1997) Equivalence trials. N Engl J Med 337:1159–1161
The GUSTO Investigators (1993) An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 329:673–682
Hornberger J, Wrone E (1997) When to base clinical policies on observational versus randomized trial data. Ann Intern Med 127:697–703
Galanos C, Freudenberg MA (1993) Mechanisms of endotoxin shock and endotoxin hypersensitivity. Immunobiology 187:346–356
Stewart TE, Meade MO, Cook DJ, et al (1998) Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. N Engl J Med 338:355–361
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273:1421–1428
Tu JV, Hannan EL, Anderson GM, et al (1998) The fall and rise of carotid endarterectomy in the United States and Canada. N Engl J Med 339:1441–1447
Wennberg DE, Lucas FL, Birkmeyer JD, Bredenberg CE, Fisher ES (1998) Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics. JAMA 279:1278–1281
Brun-Buisson C (1994) The HA-1A saga: the scientific and ethical dilemma of innovative and costly therapies. Intensive Care Med 20:314–316
Greenman RL, Schein RM, Martin MA, et al (1991) A controlled clinical trial of E5 murine monoclonal IgM antibody to endotoxin in the treatment of gram-negative sepsis. JAMA 266:1097–1102
Ziegler EJ, Fisher CJ Jr, Sprung CL, et al (1991) Treatment of gram-negative bacteremia and septic shock with HA- 1A human monoclonal antibody against endotoxin. A randomized, double-blind, placebo-controlled trial. N Engl J Med 324:429–436
Morris AH, Wallace CJ, Menlove RL, et al (1994) Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Cr it Care Med 149:295–305
Willatts SM, Radford S, Leitermann M (1995) Effect of the antiendotoxic agent, taurolidine, in the treatment of sepsis syndrome: a placebo-controlled, double-blind trial. Crit Care Med 23:1033–1039
Reinhart K, Wiegand-Lohnert C, Grimminger F, et al (1996) Assessment of the safety and efficacy of the monoclonal anti- tumor necrosis factor antibody-fragment, MAK 195F, in patients with sepsis and septic shock: a multicenter, randomized, placebo- controlled, dose-ranging study. Crit Care Med 24:733–742
Chalfin DB, Holbein ME, Fein AM, Carlon G C (1993) Cost-effectiveness of monoclonal antibodies to gram-negative endotoxin in the treatment of gram-negative sepsis in ICU patients. JAMA 269:249–254
Knaus WA, Draper E A, Wagner D P, Zimmerman J E (1985) Prognosis in acute organ-system failure. Ann Surg 202:685–693
Raffin TA (1989) Intensive care unit survival of patients with systemic illness. Am Rev Respir Dis 140:S28–S35
2nd European Consensus Conference in Intensive Care Medicine (1994) Predicting outcome in ICU patients. Intensive Care Med 20:390–397
Weinstein MC, Stason W B (1977) Foundations of cost-effectiveness analysis for health and medical practices. N Engl J Med 296:716–721
Ridley S A, Wallace P G (1990) Quality of life after intensive care. Anaesthesia 45:808–813
Tarlov AR,Ware JE, Greenfields S, Nelson EC, Perrin E, Zubkoff M (1989) The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA 262:925–930
Visser MC, Fletcher AE, Parr G, Simpson A, Bulpitt CJ (1994) A comparison of three quality of life instruments in subjects with angina pectoris: the Sickness Impact Profile, the Nottingham Health Profile, and the Quality of Well Being Scale. J Clin Epidemiol 47:157–163
Kaplan RM, Atkins CJ, Timms R (1984) Validity of a quality of well-being scale as an outcome measure in chronic obstructive pulmonary disease. J Chronic Dis 37:85–95
Chelluri L, Grenvik AN, Silverman M (1995) Intensive care for critically ill elderly: mortality, costs, and quality of life. Review of the literature. Arch Intern Med 155:1013–1022
Slatyer MA, James OF, Moore PG, Leeder SR (1986) Costs, severity of illness and outcome in intensive care. Anaesth Intensive Care 14:381–389
Freemantie N, Drummond M (1997) Should clinical trials with concurrent economic analyses be blinded? JAMA 277:63–64.
Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB, for the Panel on Cost-Effectiveness in Health and Medicine (1996) Recommendations of the panel on cost-effectiveness in health and medicine. JAMA 276:1253–1258
Linden PK, Angus D C, Chelluri L, Branch RA (1995) The influence of clinical study design on cost-effectiveness projections for the treatment of gram-negative sepsis with human anti-endotoxin antibody. J Crit Care 10:154–164
Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC (1996) The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine. JAMA 276:1172–1177
Neonatal Inhaled Nitric Oxide Study Group (1997) Inhaled nitric oxide in full-term and nearly full-term infants with hypoxic respiratory failure. N Engl J Med 336:597–604
Roberts MS, Angus DC, Clermont G, and Linde-Zwirble W T (1997) From efficacy to effectiveness: Problems in translating the results of clinical trials into cost effectiveness analyses. Med Decis Making 117:540 (Abst)
Davidson TA, Caldwell ES, Curtis JR, Hudson LD, Steinberg KP (1999) Reduced quality of life in survivors of acute respiratory distress syndrome compared with critically ill control patients. JAMA 281:354–360
Angus DC, Pinsky MR (1997) Risk prediction: Judging the judges. Intensive Care Med 23:363–365
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2002 Springer Science+Business Media New York
About this chapter
Cite this chapter
Angus, D.C., Pronovost, P. (2002). Hypothesis Generation: Asking the Right Question, Getting the Correct Answer. In: Sibbald, W.J., Bion, J.F. (eds) Evaluating Critical Care. Update in Intensive Care Medicine, vol 35. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-56719-3_12
Download citation
DOI: https://doi.org/10.1007/978-3-642-56719-3_12
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-540-42606-6
Online ISBN: 978-3-642-56719-3
eBook Packages: Springer Book Archive