To the Editor:
We very much enjoyed the thoughtful article by Ganiats1 entitled “What to Do Until the POEMs Arrive.” Delivering high-quality patient care is a challenge for practicing clinicians who often must make decisions in the absence of the best possible evidence. In many cases, the best possible study will never be done for ethical or financial reasons. For example, a recent study2 of 30,000 patients with sore throat found no benefit from using throat cultures. This is a good example of a study that uses a suboptimal design but is likely to be the best available evidence for the foreseeable future. We have coined the term SMORE (Surrogate Measure Of Reliable Evidence) to describe studies that use an intermediate outcome for which there is good evidence of a causal chain that affects patient-oriented outcomes. An example is the study3 that describes the accuracy of the physical examination to detect abdominal aortic aneurysms greater than 5 cm in diameter. Although not a direct measure of a patient-oriented outcome, another recent study4 confirms that patients with an aneurysm greater than 5 cm in diameter are at high risk for rupture and death.
We have one point that we would like to add to Ganiats’ conclusions. He notes, “Clearly, we can wait for POEMs, but such delays would paralyze clinicians and deny patients many excellent treatments.” We would add that such delays also protect patients from the harm of unproven interventions. The widespread use of encainide and flecainide before POEMs were available led to more than 50,000 premature deaths, more than all the Americans killed during the Vietnam War.5
Mark Ebell, MD, MS
Henry Barry, MD, MS
Michigan State University
East Lansing
Allen Shaughnessy, Pharm D
Harrisburg Family Practice Residency
Pennsylvania
David Slawson, MD, MS
University of Virginia
Charlottesville