OBJECTIVES: Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine. DESIGN AND SETTING: A systematic review of literature followed by web-based voting on findings of a consensus conference. PARTICIPANTS: A total of 555 clinicians from 61 countries. INTERVENTIONS: The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents' agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians' approach to interventions also were investigated. MEASUREMENTS AND MAIN RESULTS: According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians' agreement. CONCLUSIONS: Physicians' clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences.

Cardiac and Vascular Department Mauriziano Hospital Turin Italy

Cardiac Anesthesia and Intensive Care Federal Centre for Cardiac Surgery Astrakhan Russia

Cardiac Anesthesia and Intensive Care San Giovanni Battista Hospital University of Turin Turin Italy

Cardioanaesthesia and Intensive Care Civil Hospital SS Annunziata Sassari Italy

Cardiothoracic Department University Hospital of Pisa Pisa Italy

Cardiovascular Anaesthesia and Intensive Care San Carlo Hospital Potenza Italy

Center for Anesthesiology Beijing Anzhen Hospital Capital Medical University Beijing China

Department of Anesthesia and Intensive Care Azienda Ospedaliero Universitaria Mater Domini Catanzaro Italy

Department of Anesthesia and Intensive Care Mater Dei Hospital Bari Italy

Department of Anesthesia and Intensive Care San Raffaele Scientific Institute Milan Italy

Department of Anesthesia and Intensive Care San Raffaele Scientific Institute Milan Italy; Vita Salute San Raffaele University Milan Italy

Department of Anesthesiology and Intensive Care 1st Faculty of Medicine Charles University Prague and General University Hospital Prague Prague Czech Republic

Department of Medical Sciences M Aresu University of Cagliari Cagliari Italy

Division of Cardiac Anesthesia and Intensive Care AORN Dei Colli Monaldi Hospital Naples Italy

Division of Cardiac Surgery IRCCS S Martino University Hospital Genova Italy

Faculty of Medicine University of Melbourne Melbourne Australia

Institute of Cardiovascular Diseases ׳Dedinje׳ Belgrade Serbia

Intensive Care Unit Universidade de Sao Paulo Sao Paulo Brazil

Mohammed Bin Khalifa Bin Sulman Al Khalifa Cardiac Center West Riffa Bahrain

Moscow Clinical Regional Research Institute MONIKI Moscow Russia

Research Institute of Circulation Pathology Novosibirsk Russia

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