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February 21, 1996

Users' Guides to the Medical Literature: X. How to Use an Article Reporting Variations in the Outcomes of Health Services

Author Affiliations

From the Institute for Clinical Evaluative Sciences, Ontario, North York, the Clinical Epidemiology and Health Care Research Program, Sunnybrook Unit, and the Departments of Medicine and Surgery, University of Toronto (Ontario) (Dr Naylor); and the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario (Dr Guyatt).

JAMA. 1996;275(7):554-558. doi:10.1001/jama.1996.03530310060034

CASE SCENARIO  Your patient, a 78-year-old retired internist, has been complaining of increasing symptoms of benign prostatic hyperplasia. He has long-standing hypertension and coronary artery disease, with remote anterolateral myocardial infarction and bypass surgery 10 years ago. His left ventricular ejection fraction was recently documented at 20%, and he has been started on an angiotensin-converting enzyme inhibitor. Rectal examination confirms a moderately enlarged prostate, without irregularities, nodularity, or tenderness. As you discuss management options, your patient insists that transurethral prostate surgery is dangerous and that international studies of thousands of patients have proved that, as he puts it, "old-fashioned open prostatectomy is safer than that keyhole surgery." You prescribe a trial of an α-blocker, terazosin, and arrange to see him again. However, the retired internist sounds so convinced that you also resolve to look into the evidence about the two forms of prostatectomy.

THE SEARCH  Later, you sit down in