Number Needed to Benefit From Information (NNBI): Proposal From a Mixed Methods Research Study With Practicing Family Physicians

Pierre Pluye; Roland M. Grad; Janique Johnson-Lafleur; Vera Granikov; Michael Shulha; Bernard Marlow; Ivan Luiz Marques Ricarte

doi:10.1370/afm.1565

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Author response: What does the NNBI imply for clinicians?
Roland Grad

Published on: 02 December 2013
Author response: Using the NNBI for simulation studies
Pierre Pluye

Published on: 29 November 2013
Re:Interesting but potantially misleading
David C. Slawson

Published on: 29 November 2013
Interesting but potantially misleading
David Chan

Published on: 26 November 2013

Published on: (2 December 2013)
Page navigation anchor for Author response: What does the NNBI imply for clinicians?
Author response: What does the NNBI imply for clinicians?
Roland Grad, Associate professor
In his letter, Dr. Slawson calls on clinicians to use the knowledge tools we have on hand, in order to improve physician decision-making at the point of care. The British doctor Sir Muir Gray would applaud this call, as he is quoted as follows: "The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade."...
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In his letter, Dr. Slawson calls on clinicians to use the knowledge tools we have on hand, in order to improve physician decision-making at the point of care. The British doctor Sir Muir Gray would applaud this call, as he is quoted as follows: "The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade." http://www.gurteen.com/gurteen/gurteen.nsf/id/muir-gray
To operationalize the ideas so well expressed by Dr Slawson, we recently called for better systems to help physicians answer their questions by searching in knowledge resources embedded directly in the patient record.1 In particular, we called for the development of a CME module in the EMR. By this, we meant a system that would make it easier for clinicians to (1) document searches in knowledge resources that they initiated within the patient record and (2) earn CME credit by completing a validated questionnaire and thereby documenting their reflective learning. To my knowledge, no such CME module exists within any EMR. However, national physician organizations already offer CME credits for reflective learning at point of care. Automating the process as a CME activity would encourage some physicians to increase their attempts to answer clinical questions at point of care.
Dr. Chan recommends the use of standardized clinical vignettes in an experimental study to compare knowledge resources. This work could help us to know in which knowledge resources we should invest, with respect to the patient health benefits that flow from their use at point of care. I hope researchers will consider this type of work, and think about using the NNBI as an outcome measure.
For this type of study, the 53 clinical vignettes in Supplemental Appendix 3 could be used to develop standardized patients, or as examples for a future study of the patient health benefits associated with physicians' use of information from knowledge resources. These 53 clinical vignettes are further described at http://www.iamclinicalvignettes.mcgill.ca
1. Grad RM, Pluye P, Shulha M et al. EBM, CME and the EMR. Evidence-Based Medicine 2013 http://ebm.bmj.com/content/early/2013/03/05/eb-2013-101231
Competing interests: I co-developed the Information Assessment Method, which uses a validated questionnaire of the type I refer to in my letter.
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Competing Interests: None declared.
Published on: (29 November 2013)
Page navigation anchor for Author response: Using the NNBI for simulation studies
Author response: Using the NNBI for simulation studies
Pierre Pluye, Associate Professor
Thank you for making a good point about the challenges for measuring the outcomes associated with information sought in clinical settings. You rightfully pointed out that the NNBI can constitute a useful metric for simulation studies.
Competing interests: First author of the NNBI paper

Competing Interests: None declared.
Published on: (29 November 2013)
Page navigation anchor for Re:Interesting but potantially misleading
Re:Interesting but potantially misleading
David C. Slawson, Professor of Family Medicine
The United States is only beginning to have to really seriously confront the need to curtail health care costs. Canada and the rest of the world have been doing so but are still struggling. A simple math equation, value equals quality divided by cost, clarifies the three variables that are paramount to the entire problem: underuse, overuse, and misuse of medical services. Fixing underuse improves quality but also raises co...
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The United States is only beginning to have to really seriously confront the need to curtail health care costs. Canada and the rest of the world have been doing so but are still struggling. A simple math equation, value equals quality divided by cost, clarifies the three variables that are paramount to the entire problem: underuse, overuse, and misuse of medical services. Fixing underuse improves quality but also raises costs, resulting often in a minimal gain in value. Eliminating overuse and correcting misuse not only reduces cost but also improves patient quality and safety, incrementally improving quality. In this study the most frequently anticipated health benefit was avoiding an inappropriate diagnostic procedure or treatment- 14.9%. This finding by the authors of this excellent paper is absolutely crucial and needs to be told over and over and over in every clinic and hospital worldwide- the only way to solve the rapidly enveloping health care crisis will be by better physician decision making, and the only way for that to occur will be with improved methods of delivering information at the point of care. Drs. Pluye, Grad, Johnson-Lafleur, et al. have giving us an excellent tool to begin evaluating and comparing those tools. Not only primary care, but all specialties and disciplines, must now use and evaluate these tools. We've lost way too much time already.
Competing interests: ?? None declared
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Competing Interests: None declared.
Published on: (26 November 2013)
Page navigation anchor for Interesting but potantially misleading
Interesting but potantially misleading
David Chan, Professor
The NNBI is an interesting way to compare effectiveness of various clinical resources (online or otherwise). However, the method of calculating its value has a potential bias. There is no comparison group within the same clinical context. For example, when NNT (Number Needed to Treat) is calculated, it is based on ARR (Absolute Risk Reduction) which is the difference between AR of a study intervention versus a comparison intervent...
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The NNBI is an interesting way to compare effectiveness of various clinical resources (online or otherwise). However, the method of calculating its value has a potential bias. There is no comparison group within the same clinical context. For example, when NNT (Number Needed to Treat) is calculated, it is based on ARR (Absolute Risk Reduction) which is the difference between AR of a study intervention versus a comparison intervention. If the experiment is conducted using standardized clinical vignettes and the two clinical resources presented randomly to the study subjects, it may eliminate some of the potential biases.
Competing interests: ?? None declared
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Competing Interests: None declared.